

^ 





N\.- 






5^ 



^3 



EPIDEMIC MENINGITIS, 



OR 



CEREBRO-SPINAL MENINGITIS. 



BY 



ALFRED 'STILLE, M.D. 



PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE 

UNIVERSITY OF PENNSYLVANIA; PHYSICIAN TO ST. JOSEPH'S HOSPITAL AND 

TO THE PHILADELPHIA HOSPITAL, 



Looking at the disease as an object of study, I know of nothing which surpasses 
it in interest." — Gaskoin. 



V 



iS67 






^ PHILADELPHIA: 
LINDSAY AND BLAKISTON. 

1867. 

V 



^tW\ 




Entered according to Act of Congress, in the year 1867, by 

LINDSAY & BLAKISTON, 

in the District Court of the United States in and for the Eastern District of 

Pennsylvania. 



HENRY B. ASHMEAD, PRINTER. 



To THE Clinical Class of the Philadelphia Hospital, 

FOR 1866-67. 

Gentlemen : 

It is a pleasure, and indeed it is almost a duty, to inscribe this 
little work to you^ who enjoyed with me the rare opportunity of 
studying an epidemic of meningitis. It will, perhaps, serve to 
recall many things which you would otherwise have forgotten, 
and to impress you with a clearer idea of this curious disease 
than you could obtain from the fragmentary remarks made at our 
clinical conferences. 

Availing myself of this opportunity to commend your diligent 
and patient attendance upon our meetings, and to thank you for 
the many other evidences of the interest which you manifested in 
our common labors, 

I remain, very faithfully, your obedient servant, 

Alfred Stille. 

1500 Walnut Street, September, 1867. 






CONTENTS. 



Introductory, ...... 


PAGE 

9 


History, ...... 


10 


GrENERAL IdEA OF THE DISEASE, .... 


17 


Sketch of the Symptoms, .... 


19 


Symptoms furnished by the Nervous System, 
Headache, ..... 


22 
22 


Yertigo, ...... 

Debility, . . 

Delirium, ...... 


24 
24 
26 


Coma, . 


28 


Fades, . . . . 


29 


Cutaneous sensibility, .... 
Pain in the spine and limbs, .... 
Tetanoid phenomena, .... 
Clonic spasms, . ... 
Paralysis, . . . . 
Symptoms furnished by the Organs of the Senses, . 


30 
31 
32 
39 
40 
41 


The eyes — Conjunctivae, .... 

Double vision, .... 


41 
43 


Blindness, . . . . 


43 


The iris, ..... 


44 


The pupil, .... 
The ears — Hearing, ..... 


45 

46 


Expression, ..... 
Symptoms furnished by the Digestive Organs, 


46 

47 


The tongue, ..... 
Nausea and vomiting, ..... 


47 
47 


Diarrhoea; constipation, .... 

The appetite, ...... 

Thirst, ...... 


50 
50 
51 


Sore throat; aphthae, ..... 
Parotids, . . . . 


52 
52 



VI 



CONTENTS. 



Symptoms furnished by the Urinary 


Organs; 


the 


Joints, and the Respiratory Apparatus, . 


. 53 


Symptoms furnished by the Pulse, 




54 


Symptoms furnished by the Skin. 




. 56 


Dryness and moisture, 




56 


Temperature, .... 




. 57 


Eruptions, 




61 


Meningitis without eruption, . 




61 


Meningitis with non-petechial eruptions, 




64 


G-angrcne, .... 




. 67 


Duration, .... 




67 


Convalescence, . . . . 




. 70 


Sequelae — Relapses, 




71 


Mortality, . . .* . 




. 72 


Forms, . . 




72 


Anatomical Characters, 




. 76 


Exterior, .... 




77 


The scalp and cerebral membranes, 




. 78 


The ventricles of the brain, 




80 


Exudations, . . . 




. 81 


The substance of the brain. 




86 


Spinal marrow. 




. 87 


The blood, 




89 


The joints, . . ... 




. 93 


Causes, .... 




93 


Season, .... 




. 94 


Weather, .... 




95 


Local conditions, 




. 95 


Sex; age; occupation. 




95 


Debility, .... 




. 97 


War; poverty; filth; cold. 




97 


Contagion, .... 




. 99 


Prognosis, .... 




102 


Diagnosis — Positive, 




. 106 


Comparative : Sporadic meningitis 


107 


Hysteria, 


. 


. 108 


Typhoid fever, 


. 


108 


Typhus fever, . 


. 


. Ill 



CONTENTS. 


Vll 


Nature, ...... 


PAGE 

. 124 


Name, ..... 


130 


Treatment, ..... 


. 134 


Antiphlogistic method — Emetics, . 


136 


Purgatives, . 


. 138 


Depletion, 


138 


Cold, 


. 143 


External stimulants — Blisters, 


144 


Heat, . 


. 147 


Internal stimulants — Alcohol, 


148 


Opium, . 


. 153 


Cinchona and quinia. 


158 


Alteratives — Mercury, 


. 160 


Arsenic, 


166 


Iodine, .... 


. 167 


Miscellaneous — Belladonna; ergot, 


167 


Diet, .... 


. 168 


Begimen, 


171 


Bibliography, ..... 


. 172 



EPIDEMIC MENINGITIS. 



As the epidemic meningitis which has raA^aged the 
United States for the last ten or eleven years, appears 
to be approaching the termination of its career, the 
present seems to be a fitting occasion for reviewing 
its course, and studying its analogies with European 
and other American epidemics of the same disease, 
and for guarding, if possible, future generations of 
physicians against the misconceptions and mistakes, the 
confusion of ideas and the still greater confusion of 
terms, which, even now, have not altogether ceased to 
have currency among professional teachers and writers. 
We have been the more strongly moved to attempt 
placing the subject in a clear light, by the practical 
acquaintance with it, which we acquired during the 
first quarter of the present year, while studying 
about one hundred and twenty cases of the disease 
in the Philadelphia Hospital. Nearly one hundred 
of them form the subject of a very valuable Report 

2 



10 EPIDEMIC MENINGITIS. 

contributed by Dr. Githens to the American Journal 
of the Medical Sciences. In the corresponding term of 
the previous year we witnessed a still more exten- 
sive and fatal epidemic of typhus fever in the same 
Institution, where, also, thirty years before, we had 
become famihar with that fever as a resident physician 
of the hospital during the great epidemic, the history 
of which is so honorably associated with the names 
of Gerhard and Pennock. Such opportunities were 
peculiarly fitted to reveal the grounds of the common 
error of confounding epidemic meningitis and typhus 
fever, into which physicians acquainted w^ith one only 
of these affections have been prone to fall, as well as 
to illustrate the surprising variety of morbid phe- 
nomena which the former exhibits by virtue of its 
double character as a blood disease, and an inflamma- 
tion of the cerebro-spinal membranes. 

HISTORY. 

Nothing illustrates more clearly the value of mor- 
bid anatomy as an element of medical diagnosis than 
the inextricable confusion which involves nearly aU 
of the descriptions of this disease which were written 
before the scalpel revealed the lesions which essenti- 
ally belong to it. There is no doubt whatever that 
numerous histories of "Fever," of "Typhus," &c., 
related by authors of the last and previous centuries 
included cases of epidemic meningitis; but it was not 
recognized as a distinct affection until the beginning 
of the present century. Some writers, who trace it 
back to the fourteenth century would be sorely at 



HISTORY. 11 

fault if they attempted to disentangle it from the 
various epidemic diseases which the history of medi- 
cine records, and especially from that of typhus with 
which it was, and by some persons continues to be, 
confounded. When we remember that it was not 
until 1836 that, in recent times, typhus was shown 
to be a distinct disease from typhoid fever, and that 
to this day the former term is applied by many Ger- 
man writers to both affections indiscriminately, it is 
not to be wondered at that epidemic meningitis should 
have been involved in the same confusion. Indeed, 
so accomplished an author as Hirsch, misled by some 
of the early histories of the disease published in this 
country, and unacquainted with the cotemporary post- 
mortem investigations which would have enlightened 
him, concludes that the old "spotted fever" had no- 
thing in common with the affection we are about to 
study. In all of these instances the lesions found 
after death have brought order out of confusion, 
and enabled us to distinguish typhus and typhoid 
fever from one another, and epidemic meningitis from 
both of them. 

Hestricting our historical review of the disease to 
the epidemics of it which have occurred since the 
beginning of the present century, and, rising for a 
moment above its individual and local outbreaks, our 
attention is at once arrested by a circumstance which 
removes it from the category of endemic, and even of 
epidemic diseases, in the ordinary sense of the latter 
word, and entitles it to the name pandemic. Unlike 
typhus, and typhoid and yellow fevers, its rise and 
progress are connected with no antecedents of animal 



12 EPIDEMIC MENINGITIS. 

or other putrefaction; nor with any miasmatic, crypto- 
gamic or analogous agent, like periodical fevers ; nor with 
any telluric or aqueous emanation like dysentery; nor 
with a special poison like cholera, smallpox, or measles. 
All of these diseases have, moreover, a distinctly ascer- 
tainable starting point from which they widely extend ; 
or else their ravages are confined within comparatively 
narrow limits; but with epidemic meningitis the case 
is very different. Its outbreaks have occurred almost 
simultaneously in regions as widely separated as 
Europe is from America, and annually it has made a 
mid-winter attack upon towns and rural districts, the 
salubrious and unhealthy alike, completing the cycle 
of its progress in a period varying between ten and 
fifteen years. Three such periods, at least, have 
occurred during the present century. The first, of 
eleven years, began in 1805 and terminated in 1816; 
the second, of thirteen years, occurred between 1837 
and 1850; and the third extends from 1856 to the 
present time, and has already lasted for eleven years, 
during which the disease has been almost constantly 
present in Europe, but absent during four years from 
the United States. These two conditions, of simultane- 
ous appearance in widely remote places, and of an- 
nual recurrence for a series of years, characterize no 
other disease whatever. The first, indeed, is ful- 
filled by influenza; and it was perhaps a dim percep- 
tion of the analogy we have pointed out which led 
one writer, at least, (Wilson), to imagine the two dis- 
eases to be identical, a proposition which at the present 
day may provoke a smile, but hardly calls for refuta- 
tion. But no other disease than influenza affords an 



HISTORY. 13 

example of the former condition singly, and none but 
epidemic meningitis of both combined. 

The first account of epidemic meningitis within the 
period we have referred to was published in 1805, by 
Yieusseux, who at once declared that neither he nor 
any of his colleagues had ever seen a similar disease. 
It is also worthy of remark, that in this particalar 
epidemic a petechial eruption was a prominent symp- 
tom, that engorgement of the brain existed in most 
of the fatal cases, and that its historian describes it 
as "a malignant non-contagious fever." If any doubts 
should be entertained respecting the identity of this 
• disease with epidemic meningitis, they will perhaps 
be dispelled by the account which Mathey furnishes 
of a dissection made in one of the fatal cases. He 
describes a gelatinous exudation as covering the con- 
vex surface of the brain, and a yellow puriform matter 
upon its posterior aspect, upon the optic commissure, 
the inferior surface of the cerebellum, and the medulla 
oblongata.* 

In every one of the following years, until 1816, 
the same disease prevailed either in Prussia, Holland, 
Rhenish Germany, Bavaria, or the east of France, 
but no where else in Europe; while in the United 
States it began its course in 1806, at Medfield, in 
Massachusetts, and between that time and 1816 it 

* Bascombe, in his *' History of Epidemic Pestilences," speaks of a 
local epidemic at Koettingen, in Franconia, in the autumn of 1802, in 
which the young and strong were suddenly seized with pain and 
anguish at the heart and lacerating pains in the nape of the neck. In 
the worst cases the patient fainted, the limbs became rigid, and death 
closed the scene frequently within twenty-four hours from the com- 
mencement of the attack. 



14 EPIDEMIC MENINGITIS. 

extended throughout New England and into Canada, 
the State of New York, Pennsylvania, and other 
States to the South and West, precisely as it has 
done during the recent epidemic. 

We possess no record of its occurrence between 
1816 and 1822; but in the last named year, a local 
and temporary appearance of the disease was observed 
at Yesoul, in France; in 1823 at Middletown, Con- 
necticut; in 1828 in Trumbull county, Ohio; in 1830 
at Sunderland, England, and in 1833 at Naples. 

After four years of quiescence it entered again 
upon a wide and destructive career, which lasted 
from 1837 to 1850. Daring the first two years of 
its recurrence in Europe, it was confined almost en- 
tirely to France; but during the third and fourth 
years it appeared also in Italy and Algeria and at Gib- 
raltar, Avithout, however, retreating from its original 
territory, where it continued to prevail until 1819, 
breaking out meanwhile at various points of the north 
of England and in Dublin, and from 1845 to 1848 in 
Denmark. While the epidemic was thus spreading 
through Europe, it again appeared in the United 
States at places as remote as possible from trans- 
atlantic communication, and hundreds of miles distant 
from one another; in Louisville, Kentucky, in Ruth- 
erford county, Tennessee, and in Montgomery, Ala- 
bama. This took place in 1842; and in the following 
years, the disease appeared in Arkansas, Mississippi 
and Illinois. In 1848 it occurred again at Mont- 
gomery, Alabama, and simultaneously in Beaver 
county, Pennsylvania; in 1849 it existed in Massa- 
chusetts and in Cayuga county. New York, and finally 



,iii. 



HISTORY. 15 

at New Orleans, in 1850. It appears, therefore, that 
although the American epidemic began later than the 
European, it reached its period of extinction very 
nearly at the same time. 

Between 1850 and 1854 epidemic meningitis had 
ceased to be heard of, when suddenly it broke out 
with destructive violence in Sweden, a country which 
had hitherto entirely escaped its ravages, and there it 
continued to prevail during the six years from 1854 
to 1860. During this period local epidemics of very 
limited extent or sporadic cases occurred in Dublin, 
London, and in Stafford, England ; and simultane- 
ously the disease prevailed in several parts of the 
United States. On this, as on previous occasions, its 
starting points were remote from one another, as in 
North Carolina, where it appeared for the first time 
in March, 1856, and in the central portions of New 
York and Massachusetts at the commencement of 
1857. 

To return once more to Europe, we find that hardly 
had the epidemic ceased in Sweden, than it reappeared 
in Holland during the winter of 1860-61; and in the 
. following year, at the same season, it spread over a 
large extent of the Portuguese territory. Germany, 
which had remained almost entirely exempt from the 
attacks of the disease since the first and very partial 
outbreak of 1806, was now the seat of an epidemic 
as widespread as that which had pervaded France. 
Beginning slightly in the summer of 1863, it acquired 
new vigor during the next winter, and for the two 
following years devastated almost every part of 
northern Germany, but, so far as we are informed, 



16 EPIDEMIC MENINGITIS. 

penetrated but slightly into the Austrian empire. 
Simultaneously (1865) a local epidemic of the disease 
occurred in Dublin. 

The counterpart of this epidemic^ as on former 
occasions, appeared in the United States. The first 
point at which it broke out was Livingston county, 
Missouri, in the winter of 1861-62; and during the 
same season it invaded Indiana, Kentucky and Con- 
necticut. From I860 to 1864 it prevailed in Ohio, 
and during the last named year in Illinois. Cases of 
the disease occurred at Newport, Rhode Island, in 
1863, and in Vermont in 1864. In 1863 the epi- 
demic began in Philadelphia, and has renewed its 
appearance annually until the present time. During 
the same period it prevailed in Maryland, Virginia, 
North Carolina, Alabama, and other Southern States. 

The coincidences which have now been pointed 
out are among the most striking occurrences in the 
history of this singular disease, and they are, as 
before remarked, characteristic of it alone. If there 
had been anything common in the origin of its 
epidemics, as climate, soil, or water, or the social 
condition, age, sex, occupation, or habits of the 
patients, a plausible, although even then an untenable, 
explanation of their simultaneous occurrence might 
be suggested; but, in point of fact, no single circum- 
stance was common to all, or nearly all of them, except 
their outbreak in mid-winter. It follows, therefore, 
that, even at this stage of our inquiry, epidemic men- 
ingitis must be regarded as an exceptional affection, 
and, as before intimated, a true pandemic disease. 
Along with the more or less wide spread epidemics 



GENERAL IDEA OF THE DISEASE. 17 

which have now been considered, several instances 
are on record of this disease occurring in groups of 
two, three or four cases, in localities where it never 
at any time assumed the epidemic form. Not to cite 
instances of doubtful import, we shall refer only to 
those observed in England, where epidemic meningitis 
has never yet been known to prevail. In 1807, Dr. 
Gervis, of Ashburton, reported four such cases; in 
1859, Dr. Day met with two such at Stafford; and in 
1865, three cases were observed in London by Dr. 
Wilks, three by Dr. Ogle, and one by Dr. Martin. 
We shall not attempt to suggest an interpretation of 
these facts, which are not, however, without their 
significance. 

GENERAL IDEA OF THE DISEASE. 

The strangely contradictory opinions concerning 
epidemic meningitis which have been held by physi- 
cians of more than ordinary intelligence and inform- 
ation, are clearly traceable to their having seen but 
few cases of the disease, to their limited acquaintance 
with its diversified forms, or to their superficial 
study of its recorded history. No disease whatever 
wears such various masks of symptoms, behind 
which there is, nevertheless, a great uniformity of 
characteristic lesions. - While one writer classifies its 
several forms as nervous, inflammatory and comatose, 
another describes them as neuralgic, delirious, con- 
vulsive, paralytic and comatose; and a third recog- 
nizes abortive, malignant, intermittent and typhoid 
forms, to which a fourth adds the chronic form, — the 



18 EPIDEMIC MENINGITIS. 

lesions are essentially the same in all, although vary- 
ing in degree as much as congestion does from exuda- 
tion, and in extent from what is invisible to the naked 
eye to a profuse accumulation of inflammatory pro- 
ducts. Yet the degree and extent of these lesions, 
and the greater or less energy in the primary impres- 
sion of the morbid cause of the disease are the two 
elements, out of which this great variety in its phe- 
nomena arises. Just as in typhoid fever the blood 
disorder and the intestinal lesion combine to impress 
upon that disease a characteristic expression which is 
compounded of those two elements in various propor- 
tions, so that in one case the attack may terminate 
in coma before intestinal symptoms arise, or marked 
intestinal lesions are developed; and in another a 
prolonged diarrhoea and moderate fever may be almost 
the only prominent phenomena; so in epidemic menin- 
gitis the blood disease may vary through every grade, 
from extreme hypinosis to extreme hyperinosis, from 
typhoid symptoms- to inflammatory, and the nervous 
disorder present those infinite diversities in degree 
and kind which depend upon the existence of conges- 
tion or of exudation in the membranes of the nervous 
centres, on the participation of one part or another of 
the brain or spinal marrow in the change, its degree 
and extent, and on the relative proportion of the 
blood and tissue changes in the aggregate lesions. 
Hence it is, that, in the description which is to follow, 
the reader must not expect to find a photographic 
miniature of the disease, by which any one may reco- 
gnize it at a glance, but rather a succession of impres- 
sions diff'ering very much from one another, but all 



SKETCH OF THE SYMPTOMS. . 19 

of them necessary to form an accurate picture of this 
chameleon-like disorder. It will greatly simplify the 
subject, however, to bear in mind the existence in 
every case of the two elements referred to above, 
the blood disorder and the nervous disorder; for to 
one or the other of the two all of the symptoms may 
be referred. 



SKETCH OF THE SYMPTOMS. 

It will readily be anticipated that, like other fatal 
epidemic diseases, meningitis is sometimes sudden 
and sometimes gradual in its development. In the 
former case, the patient on awaking suddenly from a 
sound sleep, or, while pursuing his ordinary avoca- 
tions, may be attacked with chilliness, prostration, 
vomiting and headache, of which symptoms the last 
is often intensely distressing. As in other epidemic 
diseases, also, such seizures are most common during 
the earlier periods of its prevalence; but, later in its 
course, premonitory symptoms are more frequently 
observed. They may last for an hour or two, or may 
extend to several days; and, in general, it may be 
stated that the longer their duration the milder will 
be the subsequent attack. But the symptoms in 
either case are essentially the same; prostration, chil- 
liness, feverishness, and sometimes vomiting and 
sharp pains in the head, back and limbs. The cha- 
racter of the vomiting, as well as the absence of all 
gastric lesions, prove that it is produced by an irrita- 
tion of the brain. All of these symptoms, their suc- 
cession and degree of gravity, were as fully described 



20 EPIDEMIC MENINGITIS. 

and appreciated by North, Hale, Fish, and their co- 
temporaries during the first occurrence of the disease 
in the United States, as by Tourdes, Hirsch, Niemeyer, 
Mannkopf and other historians of recent European 
epidemics. 

In the cases which may be called regular, these 
phenomena more or less gradually assume a graver 
aspect, or usher in a heavy chill, which, in its turn, 
is followed by alarming symptoms, and especially by 
excruciating pain in the head, a livid or pale and 
sunken countenance, and extreme restlessness. The 
pulse is as often slow as frequent, and the skin but 
little, if at all, warmer than natural. The vague pains 
which opened the attack are now concentrated, and 
seem to dart in every direction from the spine, which 
is also, especially at its upper part, the seat of severe 
aching; and, in a large proportion of the cases, its 
muscles become more or less rigidly contracted, so 
that the head is drawn backwards, or the whole trunk 
is arched, as in tetanus. Trismus is not uncommon, 
and clonic spasms frequently affect the extremities; 
even general convulsions are occasionally observed. As 
these phenomena grow more decided, delirium of various 
degrees is often manifested, from mere wandering and 
hallucinations during the sleepless watches of the 
night, to violent maniacal ravings, or incoherent mut- 
terings, or the stertor of coma. As the attack 
advances, the pulse usually rises above the normal 
rate, and sometimes becomes extremely frequent; and 
the skin, although it grows warmer does not acquire 
the temperature observed in idiopathic fevers, nor 
sustain it as equably as in them. In many cases 



SKETCH OF THE SYMPTOMS. 



21 



eruptions appear upon the skin. During some epi- 
demics the only one observed is herpes labialis; in 
in others the eruption resembles roseola, measles, or 
the mulberry rash of typhus, or, from the first, it 
consists of petechise, vibices, or extensive ecchymoses. 
The tongue presents the appearances which belong 
generally to the typhoid state ; it is at first moist, then 
coated with a mucous secretion, then red and shining, 
or brown and fuliginous. There is a complete loss of 
appetite, and the thirst is not usually urgent, One or 
two liquid stools at the commencement are generally 
followed by constipation, which continues throughout 
the attack, although in very grave and protracted 
cases diarrhoea may exist and even become colliqua- 
tive. When the attack tends to a fatal issue, the 
patient generally, but by no means always, sinks into 
a soporose condition, in which muscular relaxa- 
tion, debility, and tremulousness, such as are com- 
mon in typhus fever, are associated with paralysis of 
the sphincters and of other muscles. But we have 
seen rigid opisthotonos persist until within a few 
hours of death in a case of more than the average 
duration. 

In cases which tend to terminate favorably the 
symptoms are rarely, if ever, so grave; and this re- 
mark applies more especially to the typhoidal symp- 
toms than to the derangement of the nervous functions. 
Yet, wherever the latter has been decided, the return 
to health is tedious and uncertain, and not unfre- 
quently a perfect restoration of all the functions is 
very long delayed, or, it may be, is never attained. 
Such, very briefly described, are the characteristic 



22 EPIDEMIC MENINGITIS. 

symptoms of epidemic meningitis and the usual order 
of their succession. But, as before intimated, no 
single typical case, nor any general description, can 
accurately represent this Protean affection, as a 
whole, nor convey a just idea of its numerous 
grades and multiform aspects. They can best be 
apprehended after studying the variations presented 
by the individual symptoms. To these we shall 
now direct the reader's attention. As the earliest, 
usually, to make their appearance, and as most directly 
connected with the characteristic lesions of the dis- 
ease, we shall study the 

SYMPTOMS FUENISHED BY THE NERVOUS SYSTEM. 

Headache. — This is certainly one of the most con- 
stant of all the symptoms pertaining to epidemic men- 
ingitis. Except in those malignant and rapidly fatal 
cases, where the death-blow falls with hghtning speed 
[meningite foudroyanie) , it is always present. It was 
signalized by Yieusseux and by Mathey, in the Geneva 
epidemic of 1805, by whom it was described as 
"acute" and "violent;" by North, in the same terms; 
by Fitch, as "a distressing heavy pain;" by Fiske, as 
"distress amounting almost to torture, particularly 
through the temples ;" by Williamson, as so " excru- 
ciating" that the patient cries, "oh, my head! my 
head!" Fish uses the terms "sharp and lancinating" 
to represent this pain, which he adds, "is confined to 
a small spot sometimes;" Gallup speaks of it as being 
felt "in the forehead between the eyes;" Hale says, 
" that in a few instances it increased until it produced 



SYMPTOMS. HEADACHE. 23 

delirium;" and Danielson and Mann refer to a cliild 
of fifteen months in whom the fontanelle opened 
during a paroxysm of pain. Ames includes in his 
graphic description all of these varieties in the seat 
and character of the pain. Equally characteristic 
are the terms used by European writers. Tourdes 
states that this pain "extorted cries and groans that 
could not be repressed;" it was throbbing, boring, or 
lancinating; sharp or crushing, "as if the head were in 
a vice, or nails or screws were forced into the brain." 
Even during partial coma the severity of the pain is 
sometimes attested by the contortions or cries of the 
patient, the movements of the head, or the manner 
in which the hands are raised towards it. It is gene- 
rally described as persistent in a greater or less degree 
throughout the attack; but that this is not always the 
case, the recent epidemic at the Philadelphia Hospital 
proves, where not only this pain but those which 
usually accompany it, in the spine and limbs, were 
always mitigated, and generally removed, by means 
of cups, dry or scarified, according to circumstances, 
and blisters applied upon the nape of the neck. Yet 
in epidemics of a graver type the persistence of the 
symptom is most usual, even although the degree of 
its severity may not be uniform. 

It is to be presumed that the headache, with such 
peculiarities as we have seen it to possess, ought never 
to be confounded with the constant dull and heavy 
pain in the head which is peculiar to typhus and 
typhoid fevers; on the contrary, we m.ay reasonably 
conjecture that the material condition of the brain 
must resemble, not that belonging to the fevers named. 



24 EPIDEMIC MENINGITIS. ' 

wliere no meningeal lesion exists, but that of the 
same organ when its membranes are inflamed by 
tuberculous or other deposits, or by traumatic causes. 
And such, it will be found, is the fact. 

Vertigo is another symptom of the same class. In 
the New England epidemic of 1823, it was thus de- 
scribed by Miner. ^'In all the severe, and in a 
majority of the mild cases, there was from the very 
access, before a particle of medicine had been taken, 
a peculiar deficiency of vital energy in the brain and 
the whole nervous system, so that raising the patient 
into an erect posture, would generally produce the 
same sort of vertigo, anxiety at the stomach, accele- 
ration and irregularity of the pulse, nausea, and even 
fainting, which result from a similar position after a 
oTeat loss of blood." Ames refers to '' excessive de- 
bility, giddiness, and dimness of sight," among the 
initial symptoms, but not as constant. Tiiis singular 
symptom attracted also the attention of Tourdes in 
the Strasburg epidemic of 1840-41. "Vertigo," he 
remarks, "was -dmoug the earliest spnptoms. . . . Some- 
times it confused the mind and rendered walking im- 
possible. In two cases the patients were seized with 
a giddiness, which compelled them to whirl round, 
when they fell and did not rise again." Hirsch speaks 
of an adult patient, not yet confined to bed, who was 
suddenly seized with maniacal delirium, and such 
violent vertigo that he staggered about the room like 
a drunken man. 

Debility. — "A great, surprising, and sudden loss 
of strength," North describes as "a constant and 
prominent symptom," and he adds, "syncope some- 



SYMPTOMS. DEBILITY. 2 5 

times occurs." Hence the proposed name for the 
disease, "typhus syncopalis," or "sinking typhus." 
Miner speaks of it as occurring "in some degree in 
almost every instance" and as "sometimes constitut- 
ing the first access of the disease," and describes it 
as "a death-like sinking sensation in the epigastrium." 
Fish says that "the strength of the patient, from the 
moment of the attack, was completely prostrated." . . . 
"The debility was astonishing and formed a striking 
feature of the disease." . . . The patient "found him- 
self unable to raise his hand before he was sensible 
of being ill." The symptom had previously been de- 
scribed by Strong in nearly the same terms. "The 
pulse," says Foot, " w^as asthenic, and every symptom 
indicated a great and sudden prostration of the ' energy 
of the brain and nervous system.' ... I have never 
witnessed a disease in which the powers of life are so 
suddenly and entirely prostrated." Tourdes mentions 
"a sense of lassitude as one of the initial symptoms." 
This Avas followed by convulsive phenomena, and then 
"a stage of debility in which the muscular power 
seemed annihilated," and if the patient reached con- 
valescence he was "thoroughly exhausted, and re- 
quired a long time to renew his strength." Neither 
vertigo nor prostration can, in themselves, be regarded 
as more characteristic of epidemic meningitis than of 
typhus and typhoid fevers; but their degree, the pro- 
portion of cases presenting them, and the uniformity 
with which they both, but especially vertigo, occur 
at the very commencement of the attack, in certain 
epidemics, are circumstances which have not been 

recorded of any epidemic of the two last diseases. 
3 



1 



26 EPIDEMIC MENINGITIS. 

Delirium is described as a prominent symptom by 
all of the writers upon this disease, but it is also one 
which presents extreme varieties both in degree and 
kind. Sometimes it occurs among the first symptoms 
(North), but in the more regular cases it is not mani- 
fested until the second or third day. Strong refers to 
various degrees of mental disturbance, as mild, furious, 
hysterical and reasoning delirium. Haskell, Spooner 
and Holmes describe it as less frequent in males than 
in females, and in them as often being hysterical, a 
statement corroborated by later observations ; and 
Bestor, on the other hand, describes cases in adult 
males "commencing with symptoms of violent in- 
sanity, and great muscular strength, the patient 
showing alternately signs of real madness and high 
merry delirium. I have known it require three or 
four smart men to take care of one of those maniacs." 
Fish states it to be of this description when it ushers 
in the disease, the patients som.etimes being without 
sleep for a week, but adds, that when it '^ began at a 
later period, as it did in most cases, it was more mild, 
sometimes of a playful kind, the patient being sociable 
and humorous." Precisely similar conditions are de- 
scribed by Jackson and Warren, who also associate 
the occurrence of active delirium with severe pain in 
the head. Hale, indeed, regards pain as a cause of 
the delirium. Miner speaks of an extraordinary 
clearness of intellect as usually followed by delirium 
or coma, the former of which often resembled 
intoxication, or again hysteria. In the epidemic 
of 182o, this symptom was not very prominent. 
The same is also true of the greater number of 



SYMPTOMS. DELIRIUM. 27 

local outbroaks of the present epidemic. Thus during 
the winter of 1863, it is stated that among the 
cases that occurred at Sturgis, Michigan, "there 
was not complete delirium in any case." We may 
add, that in the recent epidemic at the Philadelphia 
Hospital, there were not more than two or three cases 
of maniacal delirium. But, to return to the history 
of this symptom. The epidemic of 1848, a,t Mont- 
gomery, Alabama, presented remarkable contrasts. 
Wild and furious as well as playful delirium, like 
that above described by Bestor, was observed; but 
the general tone of the mental aberration was de- 
sponding and apprehensive. The recent epidemic in 
Massachusetts exhibited equal varieties in the cha- 
racters of the mental condition, but some degree of 
delirium was present in all of the cases. 

If we turn to European histories of epidemic men- 
ingitis an equal and perfectly similar diversity appears. 
"It was rarely that delirium was absent" says Tourdes 
"during the whole of the attack. Most frequently it 
was transient; it ceased and was renewed, and it 
alternated with other symptoms, as pain and coma. . . . 
Sometimes, excited and furious the patients struggled 
with their attendants and endeavored to escape, some- 
times vented themselves in complaints and groans, or 
incoherent words, and were restlessly active without 
any object; others remained sombre and silent." 
Several times the delirium merged into persistent 
monomania. In the epidemic of 1864^ at Dantzic, 
the proportion of cases of violent delirium appears to 
have been unusually large. Gordon describes a case 
in which the patient "woke suddenly in the middle 



28 EPIDEMIC MENINGITIS. 

of the night, delirious, began to hum tunes, to fancy 
that different people were conversing with him, &c." 

Coma has been incidentally referred to as following 
delirium. It is met with sooner or later in nearly all 
fatal cases, but rarely in a marked degree until the 
approach of death. If anything is surprising in this 
disease, it is the absence of that deep and prolonged 
stupor which characterizes the typhoid state; although 
in some cases such grave lesions affect the brain upon 
both its upper and lower surfaces, and in others so 
profound a disintegration and devitalization of the 
blood has taken place that it exudes through the 
tissues as water passes through a porous body. 

These different varieties and degrees of delirium 
are not absolutely peculiar to epidemic meningitis; 
they occur in typhus and in typhoid fever, but in the 
greater number of cases of those fevers the symptom 
is more constant and uniform, and of much longer 
duration, and is associated in g-eneral with a much 
more obscure and obtuse condition of the mental 
faculties. Another circumstance is in a great degree 
peculiar to epidemic meningitis. We have repeatedly 
observed it with surprise. It was noticed by Ames 
and other American writers, but it is best described 
by Tourdes, who says "it shows how profound the 
mental disturbance must have been, even where it 
was least exhibited. Most of the patients on recover- 
ing had totally forgotten the commencement of their 
illness. Many were astonished to find themselves in 
the hospital," &c. This complete loss of memory was 
observed in cases which had not presented such symp- 



SYMPTOMS. FACIES. 29 

toms at the commencement of the attack as would 
explain its occurrence. 

The FACIES, or expression of countenance in this 
disease is also peculiar. When pain in the head is 
severe and paroxysmal, the features are contracted 
and distorted in every manner that is indicative of 
severe suffering; when it is more persistent, the face 
assumes a fixed and rigid expression, or is at the 
same time dull, particularly after a long continuance 
of the pain has produced exhaustion. In the apop- 
lectic form, i. e. with sudden or a very rapid loss 
of consciousness, the expression is said (Tourdes) 
to be fixed and stupid, like that of a person dead 
drunk; but such terms do not imply that the features 
are turgid and purplish. In this disease we observe 
neither the dark, dull, swollen and duskily flushed 
face of typhus, nor the languid, sleepy expression 
and circumscribed flush on the cheek w^hich are so 
characteristic of typh jid fever. Except during abso- 
lute insensibility occurring in rapidly fatal cases — and 
even then the face is more frequently sunken than 
bloated, — there is a look of greater intelligence than 
belongs to the diseases mentioned, more mobility of 
the eyelids, more life in the eye, a less degree of de- 
composition of the natural expression of the features. 
Upon this very characteristic and distinctive facies 
Hirsch remarks, that the pale and sunken counte- 
nance at the beginning of the attack is altogether 
remarkable. Forget asserts that paleness of the face 
and skin generally was perhaps the most ordinary 
condition. So says Corbin, who observed it in eighteen 
out of twenty cases; and Mayne compares the ap- 



30 EPIDEMIC MENINGITIS. 

pearance in the worst cases to that of cholera. Hirsch, 
also, adds, that the condition in question was observed 
by him, not in the gravest cases only, but in a con- 
siderable number of patients who were less danger- 
ously ill. 

Cutaneous Sensibility. — Hypersesthesia of the skin 
is a symptom which, when it occurs, may be con- 
sidered as characteristic of this disease, and as sharply 
distinguishing it from the two fevers with which it 
has been more or less confounded. Strong remarks, 
that "the nerves, in some few cases, had such a 
morbid degree of sensibility, as rendered the whole 
surface of the body sore to the touch." Tourdes re- 
marked its presence even in those violent cases in 
which consciousness appeared to be extinguished. In 
many of sucb cases, however, it is quite possible that 
movements developed by reflex irritation were mis- 
taken for proofs of sensibility. He states that "cuta- 
neous sensibility was the last of the sensorial functions 
to be lost, and never until the immediate approach of 
death." In 1846, during the epidemic in Dublin, 
McDowel described the patients as being sore all 
over, and wincing upon the slightest touch, or refus- 
ing to change their position in bed, from the pain 
consequent upon the slightest movement. Burdon- 
Sanderson found it a very prominent symptom of the 
disease as it prevailed about the Lower Vistula; and 
Niemeyer, who also describes it, states, as Strong- 
did long ago, that it is sometimes followed by cutane- 
ous numbness or insensibility, which he ascribes to 
pressure upon the posterior roots of the spinal nerves 
by exudation matter. In many cases during the 



SYMPTOMS. SENSIBILITY. 31 

recent epidemic we observed this symptom. It was 
often strongly marked upon the anterior surface of 
the trunk. 

Pain in the Spine and Limbs is a symptom of the same 
origin as the one just considered, and is even more 
characteristic because more uniformly present. Among 
American observers, it has from the beginning at- 
tracted attention. North refers to violent pain in 
the limbs mounting up to the head, and often followed 
by numbness of the extremities. Fiske describes it 
in a passage, which deserves to be quoted in full: 
"Its bold and prominent features defy comparison. . . . 
In some, a pain resembling the sensation felt from the 
stinging of a bee, seizes the extremity of a finger or 
toe; from thence it darts to the foot or hand, or some 
other part of the limbs, sometimes in the joints, and 
sometimes in the muscles, carrying a numbness or 
prickling sensation in its progress. After traversing 
the extremities, generally on one side only, it seizes 
the head, and flies with the rapidity and sensation of 
electricity over the whole body, occasioning blindness, 
faintings, sickness at the stomach, with indescribable 
distress about the prsecordia; a numbness or partial 
loss of motion in one or both limbs on one side, with 
great prostration of strength. The horrible sensation 
of this process no language can describe." In equally 
precise terms it is mentioned by Fiske, Jackson, Gal- 
lup, Hale, of the earliest, by Ames and others of the 
middle period, and by Lidell, Armstrong, Borland, 
Baldwin, Parks and others of the most recent epoch 
of the prevalence of the disease in America. Quite 
as prominently it appeared in all of the European 



32 EPIDEMIC MENINGITIS. 

epidemics and sporadic groups of meningitis. Thus 
Curry described it in the cases he observed in 1806, 
in England; Gaskoin, in the Portuguese epidemic of 
1861-62; Tourdes, in France, in 1841; and all the 
historians of the recent outbreak in Germany. The 
pain most frequently begins, and generally is most 
severe in the neck, but sometimes extends to the whole 
length of the spine. It may last throughout the dis- 
ease, or be limited to its early stage, or again it may 
persist even after convalescence. Our own observa- 
tion has furnished many cases of extreme suffering 
from the symptom h-ere described, but none in which 
it was not relieved by appropriate treatment. Tourdes 
' speaks of the spinal pains, associated as they are in 
this disease, as the true pathognomonic sign of cerebro- 
spinal meningitis. They usually occur in connection 
with neuralgic pains in the extremities; but either may 
be present without the other, and, of the two, the 
pain in the spine is the more frequent. It may not 
be superfluous to mention that whatever the seat of 
the spinal pain, it is generally aggravated by pressure. 
Tetanoid Phenomena. — These are still more charac- 
teristic of epidemic meningitis than the symptom just 
described, although both originate in the same spinal 
lesions, congestion of the membranes of the cord, 
or its compression by an effusion either of serum 
or of lymph, or by changes in its proper tissue. 
These lesions will be described hereafter; we recall 
them at present to keep in mind that only true 
idea of the disease which embraces the reciprocal 
relations of its symptoms and their material causes. 
Tetanoid symptoms are by no means necessary to 



SYMPTOMS. — TETANOID PHENOMENA. 33 

constitute a characteristic picture of the disease. 
Their presence unequivocally denotes the existence of 
spinal lesions ; but the converse of this proposition is 
far from being true. There may be almost any grade 
of meningeal spinal inflammation without muscular 
rigidity. In this, as in other cases, the degree of 
irritability of the affected part is just as important an 
element in developing functional phenomena, i.e. cha- 
racteristic symptoms, as are the material tissue changes 
of the part itself. Both factors must cooperate to 
produce the result. Hence it is that in some epidemics 
the symptom is present in a small proportion only of 
the cases, even of those patients in whom character- 
istic lesions of the cerebro- spinal axis are found after 
death. This fact was repeatedly observed in the re- 
cent epidemic at the Philadelphia Hospital. A want 
of absolute uniformity in the occurrence of this symp- 
tom has led to various extravagant notions which 
have prevailed in regard to the nature of the disease, 
and to doubts, entertained even by some enlightened 
judges, of the true character of certain epidemics of 
meningitis, especially in its early history in this 
country. A more thorough study of them, however, 
and particularly a comparison of cases occurring in 
different localities, and in successive years, removes 
all doubt upon the subject, and proves the unity of 
the affection beneath its diversified phenomena. 

Thus, in one of the earliest histories of the Ameri- 
can epidemics, that of North, we find among "the 
more unusual symptoms," "a drawing back of the 
head, with a kind of clonic spasm of the muscles of 
the neck" and a "corpse-like rigidity of the limbs." 



31 EPIDEMIC MENINGITIS. 

But for this brief statement we might almost feel un- 
certain whether the disease described by himself and 
several of his cotemporaries Avas really epidemic men- 
ingitis. Fortunately, other testimony which is equally 
emphatic, remains. Thus, Lyman says, there is "pain 
and rigidity of the muscles of the neck, often, and the 
head is in many instances inclined backward;" Wood- 
ward describes the "head drawn back with spasm;" 
Jackson says the "head is sometimes drawn back 
as in opisthotonos," and Gallup states that "the form 
of tetanus, called opisthotonos, comes on sometimes 
towards the close of severe cases." To this point the 
testimony of Strong is very pertinent : "During the 
first two years," he remarks, "the extensor muscles 
of the head and neck, were, in almost every case, 
affected with true spasm. . . . This symptom, how- 
ever, disappeared with the petechial spots, and during 
the last two years was rarely observed." In an epi- 
demic which prevailed in the Valley of Virginia, in 
1812-13, Dunbar described "the head as drawn back, 
and the spine curved rather more than even in the 
w^orst cases of tetanus," at the same time that "pe- 
techiae and vibices appeared generally over the body." 
Hazeltine, also, in his account of the epidemic which 
he witnessed in York, Massachusetts, between 1810 
and 1815, says, "there were, in some cases, great 
rigidity, immobility and soreness of the limbs and 
surface; spastic rigidity of the muscles of the lower 
jaw and the posterior muscles of the neck." In all of 
the fatal cases petechise and vibices were observed. 
It is evident, therefore, although certain historians of 
the first epidemic in this country omit all mention of 



SYMPTOMS. TETANOID PHENOMENA. 35 

this symptom, that others observed and recorded it, 
which positive testimony outweighs a whole volume 
of negative evidence, and establishes the nosological 
character of the epidemic in question. As we shall 
see hereafter the anatomical proofs are similar, and 
equally strong. 

When the epidemic began in the Southwestern 
States of the Union, it was, as elsewhere, a strange 
visitor, and gave rise to the usual confusion between 
it and the ordinary local diseases. In New England 
it was confounded with "typhus," in the South with 
malarial affections. When Boling first described its 
appearance at Montgomery, Alabama, he committed 
this error, but he did not fail to mention the charac- 
teristic phenomena of the disease, so that its nature 
cannot be doubted. Very possibly, however, its type 
was modified by malarial agencies. However this 
may be, he says, "after a few exacerbations of fever, 
suddenly and unexpectedly, at the period of an ap- 
proaching paroxysm spasms resembling those of 
tetanus supervene. . . . The muscles of the abdomen, 
of the neck and jaws, and of the superior extremities, 
after the commencement of the spasms, remain gene- 
rally in a firm and rigidly contracted state. Those 
of the neck were in two instances affected, as the 
spine was bent and the head drawn permanently back 
as in opisthotonos." So, in 1847, Drs. Hicks and 
Taylor, of Whitesville, Tennessee, describe as some- 
times an initial and sometimes an advanced symptom, 
"rigidity of the posterior cervical muscles, retracting 
the head considerably backward, as in tetanus;" so 
Dr. Chester, of Union county, Arkansas, mentions 



OG EPIDEMIC MENINGITIS. 

opisthotonos in all of the four cases reported bj him 
in 1847; so Dr. Love, describing several forms of the 
disease, as it occurred in a regiment of Mississippi 
volunteers, at Vicksburg, in 1847, refers to one in 
which furious delirium ushered in the attack, and 
adds, "these cases were always attended with opis- 
thotonos of the muscles of the neck ;" and, finally, as 
regards the same epidemic, Dr. Ames, in his well known 
and model essay on the subject, dwells upon the 
tetanic symptoms exhibited, the continued opistho- 
tonos, or the retraction of the head, merely, which took 
place in a very large proportion of the cases, while 
many other patients were affected with stiffness and 
soreness of the back. In a few cases the affection 
was confined to the sterno-mastoid muscles of one or 
both sides; and in others the head was held stifily and 
not inclined forwards or backwards. 

During the next epidemic this symptom was equally 
characteristic wherever the disease was carefully ob- 
served. In 1857, says Dr. Kendall, of Onondaga 
county, New York, "others lie in a torpid state, the 
head drawn back upon the nuchse." In the same 
year we find that, in Chemung county, New York, 
the disease prevailed, and out of the forty-three cases 
of it reported by Dr. Squire, only three presented 
tetanic phenomena. Two of these, which proved 
fatal, were examined after death, and a purulent exu- 
dation was found in the one, and congestion only in the 
other, although muscular rigidity during life had been 
equally manifested in both. During the same period, 
in Madison county, New York, Dr. Saunders observed 
among the usual symptoms "contraction of the muscles 



SYMPTOMS. TETANOID PHENOMENA. 37 

of the back and back of the neck, not nnfrequently 
producing complete opisthotonos." 

The last epidemic furnishes evidence of precisely 
the same kind. Dr. Upham says, "the decubitus 
was mainly on the right side, with the head not un- 
frequently thrown back — the neck rigid and stiff — a 
partial opisthotonos." Dr. A. P. Woodward illustrates 
a proposition already laid down by us, in a case in 
which there was no opisthotonos, although the exu- 
dation upon the brain and spinal marrow was singu- 
larly profuse. Not to multiply citations, we may 
add that the symptom is prominently described by Drs. 
Frothingham, A. T.Watson,W. H. Draper, E.W. Jenks, 
and J. K. Reid, who found it in every one of ten cases ; 
F. B. Foley, J. L. Oliver, W. Anderson, and C. G. 
Page, in eight out of seventeen cases; M. Kempf, J. 
H. Hutchinson, and W. Gr. Armstrong, of Mobile, who 
speaks of tetanic rigidity of the cervical muscles with 
pain in the head and neck as the most prominent and 
almost universal symptom; W. 0. Baldwin, of Mont- 
gomery, Alabama, J. W. Moorman, of Kentucky, and 
Dr. 0. B. Fassett, of Vermont, who made the same 
observation in the epidemic of 1864; and, finally. Dr. 
Parks, analyzing the results of observation in Massa- 
chusetts, finds that out of 261 cases severe opistho- 
tonos existed in 107, slight in 80, and in "nearly all" 
of 26 cases; so that the symptom was absent in only 
48, or in less than one-fifth of the whole number. 

European epidemics of meningitis have exhibited, 
even still more uniformly than our own, the distinctive 
phenomena of spinal irritation. It was observed, but 
only in a few cases and not in an aggravated form, 



o 



8 EPIDEMIC MENINGITIS. 



during the Geneva epidemic of 1805, and still more 
slightly in the local outbreak of the disease at Ash- 
burton, England, in 1807. At Naples, in 1833, De 
Renzi found it "frequently." In his account of the 
epidemic of 1842, at Strasburg, Tourdes says, "the 
decubitus of the sick was distinguished by a backward 
flexion of the head and spine; most frequently the 
neck alone was affected, but sometimes the whole 
trunk was arched." "This symptom was exhibited 
only after the disease had reached a certain degree of 
development, and remained until death in fatal cases, 
and in others so loug as the general symptoms con- 
tinued grave. From time to time it underwent remis- 
sion or exacerbation, or alternated with convulsive 
movements, after which the trunk resumed its arched 
position. . . . Muscular contraction with rigidity was 
sometimes partial and local, and sometimes general. 
In some cases it affected the flexors of the upper ex- 
tremities. Trismus was also observed, but only in 
fatal cases." The manifestation of this symptom is 
well described by Gillkrest in his history of the Gib- 
raltar epidemic of 1844. In Leipsic, in 1851, Wun- 
derlich found opisthotonos in all of his cases. Me- 
meyer, in 1865, stated that during the epidemic in 
Baden, "this symptom was wanting in extremely few 
cases." In some that terminated fatally it ceased a 
short time before death, but much more generally it 
persisted as long as life lasted. In one case it con- 
tinued for more than two months, and in another until 
death on the forty-ninth day. The testimony of 
Hirsch is to the same effect. During the epidemic 
about the Lower Vistula, Dr. Burdon-Sanderson ob- 



SYMPTOMS. CLONIC SPASMS. 39 

served this symptom in a modified form. The head 
was thrown back as if to alleviate the muscular spinal 
pains, and it was only ^>^ien attempts were made to 
draw the head forward that the muscles became risfid, 
and even then less firmly than in tetanus. Among 
the sporadic cases occurring in London, in 1865, this 
symptom was observed by Drs. Ogle, Martin, Simon, 
and others. In the recent Irish epidemic a case oc- 
curred to Gordon, of which he says : " The patient lay 
on her abdomen, and refused to allow herself to be 
moved on her back or on either side. Her spine pre- 
sented a most wonderful uniform curve concave back- 
wards; her head was also curved backwards on the 
spine of the neck." 

Tremors and Twitching of Tendons, so common in 
typhus, are much less frequent in this affection; in- 
deed many cases do not present them at all. 

Clonic Spasms, or convulsions, although less common 
than rigidity of the muscles, have also been frequently 
observed. They were seen especially in children, by 
Vieusseux, described by Mathey, Danielson and 
Mann, Fitch, North, Miner, and many others. Forget 
pictures the violent agitation of some patients pro- 
duced apparently by extreme pain, and also speaks 
of the "wretched spectacle presented by young men, 
who but a short time before were full of health and 
strength, struggling desperately in frightful convul- 
sions which were the mournful harbingers of inevitable 
death." This statement does not imply that convul- 
sions, even when general, are necessarily fatal, for they 
often occur at the commencement of the attack in 
patients who recover. They vary in degree from 



40 PIDEMIC MENINGITIS. 

subsultus affecting particular muscles, as of the eyes, 
the face, a limb, &c. to general and epileptiform con- 
vulsions with loss of consciousness, and may be asso- 
ciated with paralysis of other parts; as where the two 
halves of the body are affected Avith the opposite con- 
ditions. 

Paralysis, or loss of muscular power in different 
degrees, has also been repeatedly met with, but less 
so than abnormal muscular contraction. North ob- 
served paralysis of the arm or leg, or of both at once, 
the latter occurring among the initial symptoms of 
the attack: to this statement Jackson adds paralysis 
of the muscles of deglutition. At Gibraltar, Gillkrest 
met with two cases of temporary hemiplegia. In 
1865, a man was ill of the disease, in Dublin, of whom 
Dr. Law says: "all his members seemed to be para- 
lyzed ; he could move neither arms nor legs." A re- 
markable case is recorded by Wunderlich, of a man 
w4io, on the second day of the disease, lost both sen- 
sibility and motility in the lower limbs and over the 
greater part of the trunk, while the left arm was also 
partially paralyzed. Yet he did not die, and five 
months afterwards had partially regained his muscular 
power. The persistence of the paralysis in this case 
is very remarkable. More frequently, if the patient 
survives, the loss of muscular power or of sensibility 
is temporary, continuing only for a few days or weeks, 
and indicating therefore with probability that the 
paralysis resulted from pressure on the nerve roots or 
centres and not from interstitial lesions. Perhaps it 
will be thought not improbable that the sudden or 
rapid and extreme prostration which occurs in many 



SYMPTOMS. THE SENSES. 41 

cases of epidemic meningitis, and sometimes in all 
that arise in a particular locality, may be due to the 
congestion or the serous effusion which precedes or 
takes the place of fibrinous exudation. That it is not 
due to the blood, or at least not to the condition of it 
which exists in typhus, is shown by the abscence of 
the peculiar stupor which belongs to that disease. 
The prostration referred to acquired for this affec- 
tion the name of "sinking typhus," and is well de- 
scribed by Miner, who particularly attributes it to a 
want of nervous power transmitted through the par 
vagum. Our present knowledge of the nature of the 
anatomical lesions in the disease would seem to justify 
an explanation of these symptoms by the pressure 
which the congestion, effusion or exudation exerts 
upon the origin of the pneumo-gastric nerve which 
associates the actions of the lungs, the heart and the 
stomach. 



SYMPTOMS FURNISHED BY THE ORGANS OF THE 

SENSES. 

The Eyes. — Abnormal conditions of these organs 
and of their functions are among the most striking, 
and, when they exist, distinctive phenomena of epi- 
demic meningitis, and add one more to the many 
striking contrasts of the disease with typhus and 
typhoid fevers. In the former of those affections a 
dark or dusky, almost purplish, color of the eye, with 
a watery condition of the conjunctiva, is a common 
and characteristic phenomenon. But it is totally un- 
like the appearance of the eye in epidemic meningitis. 
4 



42 EPIDEMIC MENINGITIS. 

In typhoid fever the eye is occasionally red, and of a 
lighter tint than in typhus; but this symptom is not 
uniform, is not even common, and the redness, when 
it does occur, is rather striated, while in the disease 
before us it is generally diffused and uniform. It 
has been observed in all epidemics of meningitis; in 
some of them characterizing every case, in others 
occurring more or less frequently. In the recent epi- 
demic w^hich we witnessed it was scarcely ever absent. 
Strong speaks of it as "a peculiar redness of the albu- 
ginea." North describes it as "redness or suffusion;" 
Ames says, very clearly, "in a few cases, principally 
among children, the conjunctiva has a pinkish tint, 
when there w^ere no distinct vessels to be seen;" in 
one of Curry's cases "the tunica albuginea was com- 
pletely suffused wdth blood." In the epidemic de- 
scribed by Tourdes, on the other hand, it was seldom 
observed, except as a symptom of conjunctivitis with 
mucous or muco-piirulent secretion, and a similar ob- 
servation has been made by other historians of the 
disease, too numerous to mention. While writing 
these pages, (June, 1867,) we visited a young lady of 
twenty-four, who presented the peculiar redness of 
the eye of which we have spoken. Two evenings 
previously she went to bed perfectly well, and was 
awaked about midnight by a violent frontal headache 
accompanied with bilious vomiting and severe pain in 
the back, but only in the loins. There was said to 
have been at the same time chilliness and fever. On 
our visit the skin was cool, the pulse feeble, and about 
60; the mind clear. On inquiry, assurance was given 
that the skin presented no discoloration; but struck 



SYMPTOMS. THE SENSES. 43 

by the sudden onset of the illness and the peculiar 
appearance of the eyes^ we urged an examination of 
the body, when the chest and upper portion of the 
abdomen were found covered with light red or pinkish 
spots of irregular form and unequal size, disappearing 
upon pressure. Within five days from the commence- 
ment of the attack, the eruption, the injection of the 
eyes, and the headache had vanished, and the pulse, 
which had risen to 70, was of good volume and 
strength. Among recent authors, Gordon states 
that the conjunctivitis is sometimes severe, with a 
profuse purulent discharge. But much more alarm- 
ing and serious affections of the eyes are frequently 
observed, some of which are transient and others per- 
manent. 

Double and even Triple Vision, was noticed by 
North, and has been observed by many others since 
his time, its cause being, doubtless, the strabismus 
which is also a frequent incident of the disease. 
Jenks mentions a case in which it continued after 
recovery from the other symptoms; Armstrong 
met with it in several cases, affecting one or both 
eyes; Gillkrest found it not unfrequent; Banks met 
with divergent strabismus, as did others, including 
Burdon-Sanderson, who observed twelve cases of 
squinting. In seven the affection was transitory, not 
lasting more than a few days; in three cases it lasted 
from one to five weeks or more. In the epidemic 
studied by Tourdes, on the other hand, this symptom 
was quite uncommon. 

Blindness has also been repeatedly observed. Fish 
states that in a few instances it was the first deviation 



44 EPIDEMIC MENINGITIS. 

from health, and was generally followed by raving 
delirium. It was sometimes attended with general 
^^numbness" or partial anaesthesia, and when this 
condition was extreme, blindness, with dilated pupils, 
quickly succeeded. In some cases sight was restored 
in a few hours, in others after a few days; but in no 
case was it permanently lost. This very brief dura- 
tion of bUndness is also noted by Ames. Jenks, 
however, refers to an example of the permanent loss, 
by amaurosis, of one eye. Lente reports a case in 
which several months after the attack, the conjunc- 
tiva was much injected, the globe shrunken and soft, 
the cornea hazy, and the lens cataractous. Similar 
cases, but of a more rapid course with entire destruc- 
tion of the eye are referred to by Love. In Europe 
analogous statements are made by Gillkrest, Ziemssen, 
Corbin, Wilson, and others. 

Inflammation of the Iris or of the Conjunctiva 
was frequently observed by Love, Upham, Jenks, 
and others, in the United States, and by Tourdes, 
Lionnet, Niemeyer, Wilson, and many more, in Eu- 
rope. Niemeyer regards all these various affections 
of the eyes as consequences of inflammation of the 
neurileme of the trunks of the nerves which supply 
the eyes. He calls attention particularly to the 
analogy between the various destructive lesions in- 
volving the eye in this disease, — ^the purulent ophthal- 
mia, the softening of the cornea, and hypopion, — and 
the changes produced in the organ by the destruction 
of the Gasserian ganglion. It seems probable that in 
some cases superficial ulceration of the cornea may be 
owing to its exposure to the air in consequence of 



SYMPTOMS. THE SENSES. 45 

paralysis of the orbicularis muscle. Burdon-Sander- 
son gives as the results of ophthalmoscopic examina- 
tion in some cases of consecutive blindness, opacity of 
the vitreous humor, synechia posterior, &c. 

The PUPIL has always been observed to vary in 
shape and size in this disease. North and Strong 
mention its alternate contraction and dilatation, and 
Danielson and Mann say "the size of the pupil varies 
suddenly, from almost wholly obliterating the iris 
down to the size of a millet seed, and then again as 
suddenly dilating." To this Fish adds, "in some 
cases this alternate contraction and dilatation con- 
tinued for an hour or two, when it disappeared; being 
succeeded by a more natural state of the eye, or per- 
manent dilatation with coma." Ames says, "the 
pupils were dilated in seven out of forty-one cases ; in 
the rest they were either contracted or natural;" w^hile 
Armstrong found them dilated in a majority of cases, 
and sometimes one pupil was contracted and the oppo- 
site one dilated. In Europe Tourdes observed dilata- 
tion most commonly; Gillkrest, oscillation; according 
to Burdon-Sanderson contraction of the pupil was 
most common at the commencement of the attack, 
even when the patient was more or less stupid, but 
dilatation took place w^hen he was roused in any way. 
Such alternations of size, however, were observed in- 
dependently of all apparent cause. In cases of long 
duration with great exhaustion "'the pupils were 
almost invariably dilated." Photophobia is not un- 
common, (Ames refers to six cases of it) ; and 
occasionally spasmodic movements of the ball have 
been witnessed. 



46 EPIDEMIC MENINGITIS. 

Hearing. — Fish observed that hearing and smelling 
were natural; but some patients lost their hearing, 
when recovering, "without any perceptible injury 
about the ear." Strong refers to three such cases. 
Jackson and Warren state that "in a small number 
of cases the disease has been followed by deafness, 
from which the patients have not speedily recovered;" 
in a few instances " purulent discharges from the ears 
have been noticed." Ames noticed "spontaneous 
deafness in a few patients," and other cases in which 
there were temporary exacerbations of deafness. 
Sometimes, also, purulent discharges from the nose 
took place; and in one case the sense of smell in one 
nostril was lost. The loss of hearing is stated by 
Draper to have been observed at Carbondale. 
Wunderlich noted it at Leipsic, and Burdon-San- 
derson about the Lower Vistula. The last mentioned 
reporter met with it in ten cases, of which three 
w^ere patients under ten years of age, the rest 
between ten and seventeen. In six of them the affec- 
tion appeared during the first few days, and in three 
during the second week. In one case it was not 
observed until the fourth week. This symptom 
appears to depend chiefly upon the pressure of the 
plastic exudation in which the auditory nerves are 
imbedded. 

Finally, as regards the physiognomy, it may be 
stated that its expression is, from time to time, as 
different as the conditions which have now been de- 
scribed. Although it may vary as much as the look 
of maniacal fury does from that of profound stupor, 
yet it must be said that its average condition does 



SYMPTOMS. THE DIGESTIVE ORGANS. 47 

not indicate either excitement or coma, or even a 
great degree of dullness. The patient moves his eyes 
more briskly than in the two forms of fever several 
times referred to, and winks their lids in a manner 
quite unknown in those affections. 

SYMPTOMS PRESENTED BY THE DIGESTIVE OUGANS. 

The TONGUE presents no characteristic appearances. 
Miner said long ago: "on the w^hole, the state of the 
tongue was of very little service in diagnosis or prog- 
nosis." He and other waiters describe nearly every 
possible aspect of this organ as regards moisture, dry- 
ness, and the color and consistence of its coatinp;. But 
all agree that it rarely grows very black and dry, and 
that this condition, when it does occur, is not of long- 
continuance. North speaks of "a bloodless appear- 
ance" of the tongue as '^a certain token of approach- 
ing death," and Fish expresses a similar opinion. Our 
own observation in the recent epidemic showed that 
the tongue was generally moist, whitish in the centre 
and at the tip and edges. In a comparatively small 
number of cases it was dry, and more or less brown. 
The fuliginous condition of the tongue, gums, cheeks 
and lips, so common in typhus and typhoid fevers 
was not observed in any case. 

Nausea and Vomiting are very constantly present 
among the initial symptoms. In yellow fever, peri- 
odical fevers, and typhoid fever, they occur as the 
direct effects of gastric irritation; in typhus they are 
rarely met with, and then as a remote consequence of 
cerebral disturbance. In the present affection they 



48 



EPIDEMIC MENINGITIS. 



are evidently of a similar origin. But as the cerebral 
lesions here are more considerable and constant, the 
symptom, as might be expected, is more uniform and 
severe. Wherever the disease has prevailed it has 
attracted attention. North describes "sickness at 
stomach and vomiting;" Danielson and Mann "nausea 
and puking, the matter discharged from the stomach 
having no unusual or morbid appearance;" Fitch, 
Woodward and Haskell describe the symptom in 
analogous terms. The terms employed by Fish in 
regard to it are similar to those previously used by 
Strong, and are worthy to be recalled as indicating 
its cerebral origin: "the affection of the stomach is 
not easily described. . . . Some called it a faintness; 
some a coldness, others a deadly feeling. . . . Nausea 
and vomiting were general, and in most cases vio- 
lent. ... In a few instances vomiting was the first 
symptom that indicated disease." It is emphatically 
referred to by Jackson, and both he and Fish state 
that bile was rarely vomited during the first few 
weeks of the epidemic. But at all periods there were 
some patients who threw up a dark green or bluish 
liquid. Gallup alludes to cases in which the vomiting 
was incessant and very copious; and he as well as 
others speak of the regurgitation rather than the 
vomiting, of large quantities of liquid. In a few cases 
the ejecta "resembled black vomit." Perhaps these 
were the same as the bluish matters referred to above. 
In other cases the liquid was rather white and viscid, 
resembling mucus. Hale furnishes a similar statement, 
and also says that "nausea and vomiting were nearly 
universal at the commencement of the fever, in every 



SYMPTOMS. THE DIGESTIVE ORGANS. 49 

stage of progress of the epidemic." "It often lasted 
six or eight hours, and sometimes for two or three 
days." "It was often excited by the patient's sud- 
denly raising himself up," thus denoting its cerebral 
origin. Miner, indeed, says "vomiting or nausea, in 
this disease, seemed ordinarily to be entirely symp- 
tomatic of an affection of the brain." In the epidemic 
of Montgomery, Alabama, (1848,) this symptom was 
frequent, but less constant; Kendall, of Onondaga, 
New York, (1857,) speaks of it as constant and dis- 
tressing; and in 1863, it was an initial symptom du- 
ring the epidemic at Newborn, North Carolina. It 
was equally constant and characteristic in European 
epidemics from that of Geneva to the present time. 
Tourdes states that nausea and vomitina almost 
always attended the onset and the first stage of the 
disease; describes the vomited matters as a greenish 
bilious liquid; and adds, as w^e have said had been 
done by others, that the vomiting cannot be regarded 
as primarily gastric, that "it is without doubt a sym- 
pathetic phenomenon occasioned by the cerebro-spinal 
affection." "Vomiting of food, with bilious matters, 
often green," was observed by Gaskoin, in Portugal, 
and by Burdon-Sanderson at Dantzic. Niemeyer 
gives similar testimony, and dwells on the sympa- 
thetic character of the symptom, but thinks it less 
urgent and persistent than in tuberculous meningitis. 
Hirsch states that in eight of thirty-nine cases there 
was no vomiting, and in four only retching, yet speaks 
of it as one of the first and most constant symptoms ; 
notices the important fact that it often occurs without 
any previous nausea, and, like others, maintains that 



50 EPIDEMIC MENINGITIS. 

"its sympathetic character does not admit of any 
doubt." 

In some epidemics, or in isolated cases, diarrhoea has 
accompanied the vomiting, and many writers describe 
the conjoined symptoms as a cholera morbus; but the 
painful spasmodic character of that affection is wanting. 
Tourdes found this symptom in a large proportion of 
cases which survived the sixth or seventh day. But 
when it is known that the trea'ment he employed con- 
sisted, /72?f^r<^//<35, of purgative eiiemata, calomel, jalap and 
croton oil, the peculiar occurrence is no longer surprising. 
If any symptom, without being characteristic, is yet 
almost uniformly present, in this disease, it is consti- 
pation. In this respect it resembles other forms of 
meningitis. " The intestines were not disordered, 
except from torpor," says Fish; "the bowels are com- 
monly "quiet" says Jackson; "the intestines," writes 
Gallup, "are as little affected in this disease as the 
head is in dysentery." The bowels are mentioned by 
Hale among the organs "that continued to perform 
their functions with nearly the same regularity as in 
health." . . . "There was much more often a tendency 
to costiveness than to diarrhoea." "The bowels were 
either natural or constipated" says Ames; and Hirsch 
found them to be so in all of sixty cases observed by 
himself. 

The appetite is naturally, and, as it were necessa- 
rily, impaired or quite lost during the painful stage 
of the disease, but once this period has passed a desire 
for food is generally exhibited. Fish thus alludes to 
the symptom in question: "The appetite is diminished, 
but it is not always so entirely destroyed as in most 



SYxMPTOMS.— THE DIGESTIVE ORGANS. 51 

other acute diseases. Children particularly some- 
times express a strong desire for food." A similar 
statement is made by Jackson, and by Hale, who also 
says, "some patients would take food in considerable 
quantity, with almost as much relish as in health." 
'•No sooner is the violence of the disease abated" 
says Strong, "than the appetite generally returns, 
and the stomach craves, receives, and digests animal 
food with great freedom and without any ill effect." 
Tourdes states that "a premature desire for food was 
generally remarked; the patients, even while in im- 
minent danger, clamored for food and endeavored to 
procure it. Digestion was easy, but the restoration 
of flesh and strength was by no means proportioned 
to the reestablishment of this function." It need 
scarcely be remarked that these conditions of the ap- 
petite contrast very strongly with such as are common 
in typhus and typhoid fevers. 

It is very noticeable that, as Jackson remarks, 
"there is seldom any remarkable thirst; in a few cases 
it has not been at all greater than natural." An ap- 
parent contradiction to this statement is given by 
Hale, when he says "the thirst was extremely 
urgent." But he immediately adds that it was 
"peculiar in its nature." It was not a desire for 
"cool and acid drinks," which, "except in a few 
instances were disagreeable, and those which were 
warm and aromatic were demanded in their stead. . . , 
Their aromatic quality seemed to operate like a cor- 
dial, to remove the sensation of depression, which 
w^as constantly felt at the stomach." Tourdes states 
that "thirst was slight and appeared late; in only 







! 

i 

! 




1 52 


EPIDEMIC MENINGITIS. 



two cases did it exist at the commencement of 
the attack." And such is the general testimony upon 
this point. But it is not without exceptions. In the 
recent epidemic in the Philadelphia Hospital, the 
patients were clamorous for fluids. 

In certain of the early American, and in some other 
epidemics, sore throat is mentioned among the symp- 
toms. North found it an almost constant premonitory 
indication; Fish states that "some patients complained 
of a sore throat, w^hich, on examination, presented the 
same appearance as in cynanche maligna, except the 
swelling of the tonsils." Jackson, referring to such 
cases, remarks that "the fauces are found very red, 
but not swollen in any part." Hale adds that some- 
times there was "a swelling and inflammation of the 
gums and fauces, which was accompanied with partial 
salivation." Among European observers. Levy is the 
only one, as far as we know, who mentions any simi- 
lar condition. He speaks of a thin pearl-colored, or 
whitish band upon the gums, which, in one case, in- 
vaded the fauces. 

Aphthje have occasionally been met with; and 
both American and European reporters mention the 
occurrence now and then of swelling of the parotid 
glands. Jackson refers to it as "slight." Jenks saw 
"sw^elling of the cervical and submaxillary glands in 
one fatal case." For ourselves, we met with two or 
three cases of suppurating parotids in the late epi- 
demic. Tourdes observed parotitis in two fatal cases; 
and Hirsch ranks this affection among the rarer acci- 
dents of the disease. 



SYMPTOMS. ^THE URINARY ORGANS^ JOINTS, ETC. 53 

THE URINAEY ORGANS, JOINTS, AND RESPIEATORY 

APPARATUS. 

The urinary organs have not exhibited any charac- 
teristic or uniform phenomena in this disease. Some- 
times the flow of urine has been diminished, sometimes 
profuse. From the beginning of its history cases of 
retention, and sometimes of incontinence of urine have 
occurred, and others of dysury. Some of these have 
evidently been due to an impaired muscular power 
in the bladder, others to a blunted perception in 
the nervous centres, and others probably to the in- 
fluence of cantharides absorbed from blistering plas- 
ters. The urine has been found, in some cases, to 
contain albumen, in others cylindrical casts, or blood 
corpuscles. These deposits have sometimes occurred 
when blisters had not been applied. Hirsch, Greene, 
Morland and others report cases in which albumen 
existed, or there was a phosphatic deposit, while the 
chlorides were diminished. In one case the urine 
contained albumen, granular casts, and pus cells, but 
no urea could be detected in it. 

The condition of the joints illustrates the predomi- 
nance of the blood element in some cases. In the 
Report of Jackson and others, it is said, "In some 
cases swellings have occurred on the joints and limbs. 
These have been very sore to the touch, and their 
appearance has been compared to that of gout. The 
parts so affected feel as if they had been bruised. 
These swellings arise on the smaller as well as on 
the larger joints, and are often of a purple color." 
Gallup says "the joints are sometimes affected with 



54 EPIDEMIC MENINGITIS. 

swelling and extreme soreness, resembling rheumatism, 
but not attended with so much swelling." Upham 
mentions "synovitis" as an occasional incident of the 
disease; and Niemeyer remarks that "inflammatory 
effusions in the joints which were frequently observed 
in France, were not entirely wanting in the epidemic 
of Rastatt." In one case various joints of the upper 
and lower extremities were moderately sw^ollen and 
exceedingly painful when handled. Effusion, without 
redness, affecting the knee joint was observed by 
Gordon. 

Respiration. — Jackson reports that it was much 
and variously affected; but, in general, difficult. 
Tourdes states that it was sighing, labored, and in- 
terrupted. Burdon-Sanderson says "its embarrass- 
ment was marked by a slow labored inspiration, fol- 
lowed by a quick inspiration and a long pause." In 
fatal cases the approach of death was often denoted 
by gurgling rhonchi, due to a serous effusion in the 
air-tubes. Pneumonia is not a very unusual accom- 
paniment, of which we have seen several examples. 
The suspirious and interrupted respiration just re- 
ferred to is of the same character, but not so marked, 
as in tubercular meninsritis. It is most distinct in 
cases which present tetanic symptoms, paralysis, and 
other evidences of central cerebral compression. 

SYMPTOMS FURNISHED BY THE PULSE. 

In the last named author's history of epidemic 
meningitis, it is said to be quite impossible to 
establish a rule for the variations of the pulse in fre- 



SYMPTOMS. THE PULSE. 55 

quency, and that it can only be stated, in general, to 
be small, thready, weak, and intermittent in cases 
tending to a flital issue, and especially in those which 
rapidly run to such a termination. Only in rare and 
altogether exceptional cases is it full and tense. 
Moreover, its rate and other qualities are subject to 
repeated and often inexplicable variations. These 
general statements are borne out by the authors to 
whom we shall now refer. 

North declares that "increased frequency of the 
pulse" is not "a prominent symptom of this disorder." 
Fish says '^the pulse w^as always extremely weak, 
feeble, and depressed: in most cases more frequent 
than in health; in others it was imperceptible on the 
attack, and until it was restored by stimulants. There 
was not, before or after the chill, any increase of 
arterial action; on the contrary, where the disease 
was left to its own course, the pulse grew more feeble 
until death took place. In some instances, though 
rarely, in fullness and frequency it did not vary from 
a healthy state." Jackson, besides the characters 
just described, remarks that the pulsations '^are re- 
markably variable, so that in the course of an hour, 
and indeed in much less time, they change from quick 
to slow, and from strong to feeble, and vice versa." 
Gallup confirms these statements, adding, that "in 
fatal cases the pulse increases in frequency until 
nothing but a faint, tremulous, retiring motion is 
felt." A remark of this author is confirmed by Hale, 
viz., that in a certain number of cases the pulse is at 
first full and hard. Miner reports that, during the 
epidemic he described, "every variety of pulse oc- 



56 EPIDEMIC MENINGITIS. 

curred, except the strong and hard, and this often in 
the same patient." In many mild cases, and in most 
of the others, until the period of fatal sinking, it was 
rarely so frequent as in health. It also, sometimes, 
from being pre ternatu rally slow became very rapid, 
rising from forty, or even twenty-seven, in a minute, 
to a hundred and thirty. Nor was this sudden change 
always a fatal sign. Muscular exertion, rising from 
the recumbent posture, &c. sometimes doubled its 
frequency, besides producing considerable irregularity. 
Some fatal cases were attended with distressing pal- 
pitation of the heart. Not to prolong these citations, 
however important they may be for exhibiting the 
peculiarities of the disease, we will simply add that 
substantially the same account of the pulse is given 
by Kendall, Jenks, Armstrong, Morland, Githens, 
and other American observers, and by Mathey, 
Tourdes, Gillkrest, Lionnet, McDowell, Gaskoin, 
Law, Gordon, Wunderlich, Niemeyer, and Burdon- 
Sanderson, among European writers. Diminished 
force, and volume, and a tone so much impaired that 
slight causes produce extreme variations in its rate 
and rhythm, are, therefore, the characteristic qualities 
of the pulse in this disease, and those by which it is 
distinguished from the fevers to which it bears a 
superficial resemblance. 

SYMPTOMS FURNISHED BY THE SKIN. 

The condition of the skin as regards dryness and 
moisture is various. Jackson states that, "in the 
early stages the skin is perhaps invariably dry ; at a 



SYMPTOMS. SKIN, TEMPEEATURE. 57 

later period spontaneous sweats have broken out on 
the head, chest, and superior extremities." On the 
other hand. Fish declares that "it was very difficult 
to excite a sweat or preserve a moist skin after it had 
been procured." Hale says that the skin "was moist 
and rather inclined to profuse sweats." He however 
seems to refer to the effect of diaphoretic measures 
rather than to spontaneous perspiration, for he adds, 
"after a diaphoresis was once produced, if the measures 
which caused it were pursued with the same vigor, it 
ran into a profuse sweat." Any one who is acquainted 
with the violent measures then employed for the pur- 
pose, will feel no surprise at the result. Yet Miner, 
who condemned such treatment, points out the fact 
that although the skin " was seldom much inclined to 
spontaneous moisture, there was in a few instances a 
morbid drenching perspiration." Preciselj^ similar 
observations were made during European epidemics, 
as Hirsch relates. 

Temperature. — Conditions of the pulse such as 
have been described would hardly be compatible with 
an uniformly high temperature of the skin, and, in- 
deed, the variations are equally striking in both. As 
the pulse never acquires the force and sustained fre- 
quency which belongs to it in pure inflammations or in 
idiopathic fevers, so the heat of skin is always less 
than in those affections, and is constantly undergoing 
vicissitudes such as are observed in no other disease. 
The early remarks of North upon this subject have 
been too little heeded. Speaking of frequency of 
pulse and heat of skin as involved in the definition 

of fever, he adds, "neither of these are prominent 
5 



58 EPIDEMIC MENINGITIS. 

symptoms in the disorder. Cases occur, it is true, in 
which the temperature is increased above the natural 
standard, but these are rare." In relating a case, 
also, he remarks, ^'her heat, as often as it was mea- 
sured, was found natural; pulse eighty." According 
to Strono;, "a diminution of heat may be considered as 
among the most striking symptoms of this disease." . . . 
"In more than a hundred cases there were few in 
which the heat was up to the natural standard, and 
rarely any in which it was above." Foot says, "the 
degree of heat rarely exceeded the healthy standard, 
and fever constituted a very inconsiderable item of 
the complaint." Fish states that "sometimes the 
skin was of a natural temperature, but more gene- 
rally it was below it;" Gallup mentions coldness of 
the skin at the beginning of the disease, but adds, 
that in the act of sweating a high heat was sometimes 
observable. During the early part of the epidemic 
of which Hale records the history, he found " the 
skin dry and parched," but "the limbs often cold and 
numb;" and at a later period the initial coldness per- 
sisted until it was dispelled by external means. Miner, 
writing of the epidemic of 1823, states that "in almost 
every case the skin was preternaturaUy cool for seve- 
ral of the first days, and subsequently, in temperature, 
it never exceeded the standard of health in more than 
three or four cases. . . . Sometimes, though rarely, the 
patient would complain of a general sensation of heat, 
though to the feel of the attendants, he would be 
actually cold. ... If increased heat and increased fre- 
quency of the pulse are a part of the definition of 
fever, a great majority of the patients had no fever at 



SYMPTOMS. TEMPERATURE. 59 

alir Jenks says that "the heat of the surface was 
less in all cases than is usually observed in acute dis- 
eases." In forty-two cases, with dry skin, Ames 
found that "the natural temperature preserved in four- 
teen, the heat was below the normal standard in 
seventeen cases, and above it in eleven. . . . There 
was never any pungent heat in the skin; in the greater 
number in w^hich it was above the natural tempera- 
ture, it was still below ordinary febrile heat." And, 
finally, as regards American testimony, we may add 
that the conditions above described were all repre- 
sented in the cases of the late epidemic at the Phila- 
delphia Hospital. The calor mordax which, the year 
before, had been so prominent a symptom in the 
typhus epidemic, was no more met with, and the 
thermometrical observations of which Dr. Githens 
has furnished an account, prove that the temperature 
of the body in this disease is lower than that recorded 
of any other fever or inflammatory affection. The 
highest temperature in different cases varied between 
100° and 105°, while in two cases it was below 100°. 
In European epidemics the same conditions of the 
bodily temperature were observed. Tourdes describes 
them very distinctly in the following passage. "At 
the onset there was no fever, even when the pulse 
was accelerated. The temperature of the skin was 
natural or sometimes even lowered; and there was 
always a complete absence of fever in cases which 
terminated fatally within the first few days. But when 
the attack was of more than a week's duration, a true 
fever was lighted up which remained until convales- 
cence or death. This fever was of the continued type, 



60 EPIDEMIC MENINGITIS. 

but presented marked and regular exacerbations, which 
took place in the afternoon along with an aggrava- 
tion of the other symptoms. The form of the fever 
was sometimes, although rarely, inflammatory; more 
generally it was typhoid." Gillkrest states that "a 
high febrile movement took place only in a limited 
number." Lionnet says that the skin "rarely felt 
hot." The following observations, if not more posi- 
tive, are, at least, more precise. Niemeyer calls 
attention to the very slight increase of temperature 
during the first and second days of the attack, viz. to 
101° — 103°. In one case, on the second day, the 
temperature in the rectum was only 99°. Wunder- 
lich's special study of temperature in disease gives a 
peculiar value to the following results. He found 
fever, but of very unequal degrees, in all cases. The 
maxima of temperature were also various. In three 
cases, at the point of death, the temperature was 107°, 
108° and 110°, respectively; in another case at the 
beginning 101.7°, and after several days 103°. In 
two rapidly fatal cases the temperature rose as death 
approached. In another fatal case the temperature, 
morning and evening, on two successive days, was 
101.5° and 103°, 100° and 103.4°; and on the third 
day,103°,106.2°,106°and 107.5°. Burdon-Sanderson 
found that in adults the temperature varied from 100° 
to 104°, and in children was still higher. Exacerba- 
tions of pain were always accompanied with an in- 
crease of the heat of the skin amounting to 2° or 3°. 
The extreme irregularity of the thermometrical results 
in this disease is regarded by Hirsch as one of its 
most distinctive characters. Ziemssen, quoted by 



SY]\rPTOMS. ERUPTIONS. 61 

the last named author, states, as the result of his 
examinations, that "the temperature is so fluctuating 
that few of the curves representing it coincide." This 
irregularity in the results of thermometrical observa- 
tions in epidemic meningitis adds another to the many 
features which distinguish that disease from typhoid 
fever and typhus. The maxima and minima in these 
several affections may not be materially different, but 
while in the two last named the temperature is pro- 
gressive and is steadily maintained for several, or 
even for many days; in the former it is irregular and 
unsteady, now advancing, now subsiding, and all 
within a period of time much shorter than in the two 
fevers with which it is compared. And further, while 
in nearly every case of typhoid fever and of typhus 
the temperature is high, viz. above 103°, in one-third, 
at least, of the cases of epidemic meningitis it is below 
that degree. 

Eruptions. — A personal study of the disease, as 
well as an examination of the recorded observations 
of others, makes two points very plain, viz: that 
in a large proportion of cases no eruption at all is 
present; and that eruptions of the most various 
characters may appear upon the skin. Following the 
plan hitherto pursued, we shall cite the records upon 
each of these two propositions. 

Cases of Epidemic Meningitis without any Erup- 
tion. — North emphatically testifies that "eruptions 
are by no means a necessary attendant upon the dis- 
ease;" and again, "they are by no means a constant 
or frequent symptom." Strong says, "these spots, 
which in 1806-7 marked almost every case, in 1808-9 



62 EPIDEMIC MENINGITIS. 

were rarely observed." Fitch writes, "there are, 
however, some even among fatal cases without any 
such appearances (petechise and vibices) on the skin." 
Dr. Woodward says "an eruption on the skin so sel- 
dom appeared that it could no longer be considered a 
characteristic symptom of the disease." Haskell 
makes the statement that "neither the spots nor the 
eruptions are inseparably connected with the disease." 
All of these quotations are taken from the single 
volume of North on "Spotted Fever," and more might 
easily have been added. "In 1807, when the spot- 
ted fever first appeared at Hartford," writes Fish, 
"there were but few cases without petechise or livid 
spots : in the following years they were less common, 
and since then they have not been seen in that place, 
before death." Jackson and his colleagues declare 
that "they occur in comparatively few cases of the 
disease." Hale remarks very pointedly, "I have 
hitherto said nothing of any spots upon the skin, 
although their real or supposed appearance has in 
many places given a name to the disease. ... I have 
never observed any tendency to the production of 
these spots, while the skin was moist, except in the 
fatal cases already mentioned." According to Gallup, 
"the eruption is not a constant attendant. . . . The 
proportion of cases which had distinct eruptions may 
be estimated at one-sixth;" and Miner informs us that 
"not more than two or three cases were, this season 
(1823), attended with petechias." Coming now to 
the Southwestern epidemic of 1846 and subsequent 
years, we find no mention of any eruption among the 
first cases which were reported by Boling; and in the 



\ii „ 



SYMPTOMS. ERUPTIONS. 63 

minute and accurate history furnished by Ames, it is 
stated that petechial spots existed in only one case. 
Hicks, Taylor and White appear to have observed 
them "in many of the more violent cases." Due al- 
lowance must here be made for the fact that many of 
the patients were negroes. If we study the history 
of the late epidemic, the evidence is to the same pur- 
pose. Kendall remarks, ''probably a majority have 
no petechise at all; even some of a fatal character 
have not exhibited them." In Squires' »very interest- 
ing narrative an eruption is mentioned in twenty-five 
out of forty-three cases. Upham found petechise 
"not an unfrequent manifestation." Black reports 
seven cases, in one only of which petechise are men- 
tioned. Corson speaks of observing petechise "many 
times; Anderson, "in some cases;" Fassett, in only 
seven out of twenty, and Page, in eight out of six- 
teen cases; and in the Massachusetts returns we find 
that rather more than one-half, 59 per cent., presented 
some morbid appearance of the skin. Finally, during 
the recent epidemic observed at the Philadelphia 
Hospital, there was no eruption whatever in thirty- 
seven out of ninety-eight cases. An eruption of some 
sort was therefore present in 62 per cent, of these cases. 
In European epidemics of meningitis the proportion 
of cases in which a general eruption existed was 
smaller still. In the Geneva epidemic of 1805, a 
considerable proportion of cases at the point of death 
presented purplish spots, some earlier than this, and 
some after death only. The same circumstance was 
observed in 1807, at Ashburton, England; in the 
Neapolitan epidemic of 1833, and in that which oc- 



64 



EPIDEMIC MENINGITIS. 



curred in Dublin in the present year (1867), ecchy- 
moses were often present and in a very marked decree. 
In the Strasburg epidemic, on the other hand, only 
three cases of petechise were observed by Tourdes; 
at Rochefort and at Versailles, in 1839, they were 
"rarely" noticed; at Gibraltar, in 1844, they do not 
seem to have been observed; in 1848-9, at the Val de 
Grace^ they do not appear to have attracted atten- 
tion; at Petit-Bourg they were not noticed, although 
the state of the skin in other respects was fully de- 
scribed. In Prussia, in 1865, neither Burdon-San- 
derson nor Wunderlich mentions petechise or vibices 
as occurring during life; JMiemeyer saw petechiae in 
one case only; Klebs found them in "several" rapidly 
fatal cases; and Hirsch, after mentioning their "occa- 
sional" presence, is obliged to draw upon American 
authors for an account of their aspect and time of ap- 
pearance. Finally, among the ten cases reported by 
Dr. Law, of Dublin, in 1866, not one had a "pete- 
chial" eruption. Thus it is evident that, taking the 
whole of the cases of epidemic meningitis in Europe 
and in this country, the number of those in which 
petechise were present formed but a small propor- 
tion, — probably not one-tenth — of the whole. 

Cases oe Epidemic Meningitis with various Erup- 
tions, NOT Petechial. — Strong speaks of efflorescences, 
carbuncles, pustules and buboes; North describes a 
"bright red" eruption; Woodward, "efflorescences of 
various sizes and shapes;" Haskell, &c. "a red fiery 
eruption, sometimes in clusters and sometimes in large 
and distinct pustules;" Bestor, "bright red spots," an 
"efflorescence resembling measles," and an "'uniform 



SYMPTOMS. ERUPTIONS. 65 

redness like erysipelas;" Fiske, "a miliary eruption," 
and sometimes '4ike the nettled-rash;" Fish, an "efflo- 
rescence resembling that of scarlatina;" Jackson, all of 
these different forms, and also large bullae, as if pro- 
duced by cantharides; and Gallup, Hale and Miner 
confirm these statements from their own observation. 
Ames observed "herpes labialis," so common in cer- 
tain European epidemics, in several instances; Ken- 
dall, spots of "a scarlet or red rose color," as well as 
petechise; Squire, "cherry-colored spots," as well as 
petechise and ecchymoses; Jenks, "large elevated 
spots of the size of a twenty-five cent piece, of very 
dark color, presenting outside of the dark color a blis- 
tered appearance;" Reid, "an exanthematous eruption 
of short duration;" Foley, "peculiar small spots of a 
Spanish-brown color;" and Fassett, "an eruption 
which was petechial in four and ery thematic in three " 
cases. The recent epidemic which we witnessed fur- 
nished examples of nearly every form of eruption 
met with in this disease. They have been correctly 
enumerated by Dr. Githens as "erythema, urticaria 
and petechial mottlings." He adds, "hemorrhagic 
ecchymoses, or vibices, were not present in any case. 
Of ninety-eight cases recorded, thirty-six had marked 
petechial eruptions, not disajDpearing under pressure; 
thirteen had mixed petechise and erythema; nine ery- 
thema and urticaria." Herpes labialis was noticed in 
a few cases. Tourdes was, we believe, the first who 
resfarded the last mentioned exanthem as character- 
istic, at least by its frequency, of this disease, and 
other observers have noticed it; but it is certainly 
much less common as a symptom of epidemic menin- 



66 EPIDEMIC MENINGITIS. 

gitis than either the roseolous or the petechial spots. 
This author, as well as a few others, occasionally 
met with the lenticular rose-colored spots so usual 
in typhoid fever; and the other exanthematous erup- 
tions have occurred in a greater or less number of 
cases in nearly all European epidemics ; but none 
of any kind, except herpes, occurred so frequently 
as to suggest to any one, except the Neapolitan, De 
Renzi, the idea of employing it to designate the dis- 
ease. 

In the Dublin epidemic of 1866-67, and for the 
first time in Ireland, a great variety of eruptions such 
as herpes, a general vesicular eruption, urticaria, 
bullae, &c., was observed. Gordon described "a dis- 
tinct eruptio7i, which comes out with great rapidity, 
is found over all parts of the body, but chiefly on the 
lower extremities; is of a very dark color, sometimes 
very deep brown or purple, or even black; the spots 
are of various sizes and shapes, some small and round, 
others large and irregular; some appear like large 
spots of very black purpura, only more mottled and 
more irregular in color and shape; others are more 
confined and raised above the level of the skin, con- 
sisting in effusion into its substance." These appear- 
ances lead the author to remark that they do not 
"constitute or indicate any new type of disease;" but 
he did not sus^orest that they denote any affiHation 
with typhus. On the contrary, he resorted to the 
history of epidemic meningitis in this country and on 
the continent of Europe, to show that they especially 
belong to that disease. These various eruptions have 
been regarded by Law, Gordon and Hayden, as being 



SYMPTOMS. CAUSE OF DEATH. DURATION. 67 

directly dependent upon the cerebro-spinal lesions 
which are characteristic of the disease. In support 
of this view, cases are cited in which traumatic and 
other lesions of the brain and spinal marrow, chorea, 
and powerful mental emotions have been accompanied 
or followed by eruptions upon the skin. In some 
cases gangrene of the skin has been noticed where the 
spots have been peculiarly dark, and occasionally, as 
in typhus, from prolonged pressure. 

The cause of death in many of the more rapid cases is 
sometimes coma; but in some others, equally rapid, and 
attended w^ith all the marks of dissolution of the blood, 
consciousness is but little impaired until the actual 
imminence of death. In many others, fatal in the midst 
of a well marked attack, death appears to depend 
upon asphyxia due to a pressure upon the medulla 
oblongata; in others, again, a slow and gradual asthenia 
exhausts the powers of life, sometimes leaving the 
mind clear until the approach of dissolution. 



DURATION, CONVALESCENCE, SEQUELS, MOR- 
TALITY. 

This affection, which in so many respects is singu- 
lar, is altogether peculiar in the irregularity of its 
duration. In typhus the usual date of convalescence 
is between the thirteenth and sixteenth days, and that 
of death in fatal cases very nearly the same ; in typhoid 
fever the attack exceeds three weeks, on an average, 
whether the patients recover or die. In contrast with 
this long duration, and this regularity of development, 
decline, and death, all observers of epidemic meningitis 



68 EPIDEMIC MENINGITIS. 

agree that it runs its course with such unequal speed 
in successive cases that no general average of practical 
utility can be formed in regard to it. Strong says, 
^'the disease appears in ever}^ shape, from the dread- 
ful plague, which baffles all medical skill, and destroys 
life in five hours, down to the mild disease, which, if 
properly treated, will confine the patient only a few 
days." . . . Of twenty patients, ^^seven died in less 
than twenty-four hours, five in less than forty-eight 
hours, three in less than seventy-two hours, and the 
remaining five from the third to the seventh day." 
North states that "unless the patient recovers, he 
commonly dies within the first twelve, twenty-four or 
forty -eight hours." If he recovers, the "attack runs 
into the form of a mild typhus of uncertain duration." 
In the epidemic described by Fish, "death took place, 
at different periods, between eighteen hours and seven 
days," and, he adds, "there have been instances of 
patients living ten or twelve days, and then sinking 
under the disease." Jackson, &c. besides confirming 
these statements, show "that even in cases where the 
attack has been very violent, and the powers of life 
overwhelmed at first, the patient has so far recovered 
as to be very comfortable in three or four, days, suf- 
fering only a slight debility." Of such, we, also, haA^e 
seen numerous examples. Gallup confirms all of these 
statements, and adds, "the common period of termi- 
nation was somewhere between the fourth and the 
seventh day;" and this was precisely the average du- 
ration of Upham's cases at Newbern, North Carolina. 
Hale remarks: "in more than half the cases my visits 
were not extended beyond the first week." Ames 



SYMPTOMS. DURATION. 69 

gives the extremes of duration as fifteen hours and 
fifty days; but by far the greater number terminated 
on the fourth day. This substantially was the result 
of Armstrong's observations in the recent epidemic at 
Mobile. Fassett, indeed, states that during the Ver- 
mont epidemic, "in no case did recovery take place 
in less than from three to five weeks;" but Ketchum 
describing the same epidemic says, "several lived five 
or six weeks from the date of the attack and then 
died " with brain symptoms, " while some lingered for 
three or four weeks with dilated pupil, deafness, opis- 
thotonos, pain in the head, semi-delirium, and then 
died. In most of the patients that recovered the 
symptoms improved in forty-eight hours. ... It is my 
experience that the duration of the disease is indefi- 
nite." Kempf says, "the duration of cerebro-spinal 
meningitis is from twenty-four hours to two or six 
days." The returns analyzed by Parks shoAv that of 
ninety-five fatal cases, the duration was five days or 
under in sixty-six; eight days in one; and ten days 
or over in twenty-eight. In cases of recovery the 
duration was altogether indefinite, viz. from ten days 
to four or five months. Githens also shows the dis- 
ease to be of uncertain duration. The acute attack 
rarely lasted through a fortnight; in a few cases the 
patients were declared convalescent in the first week. 
We have seen many slight but distinctly marked 
cases fully convalescent within the period last named. 
These references will perhaps suffice to impress upon 
the reader the peculiar uncertainty of the duration of 
epidemic meningitis. We might, were it not super- 
fluous, illustrate the point more fully by citations from 



70 EPIDEMIC MENINGITIS. 

European writers. Let it suffice to quote the expres- 
sive phrase of Tourdes, "the disease is distinguished 
by the slowness of its cure and the rapidity of its 
fatal issue;" and the conclusion of Hirsch that "its 
duration is between a few hours and several months." 
Convalescence. — It will be inferred from the last 
paragraph that convalescence from epidemic menin- 
gitis is very irregular and uncertain. In this respect 
it bears a certain analogy to typhoid fever; for in 
both affections the long and unsteady progress of the 
return to health is owing to a local lesion, which may 
be present in every possible degree. Fish and Gallup 
among American, and Tourdes and Gillkrest among 
European authorities, dwell upon the rapid and ex- 
treme prostration and emaciation which attend the 
attack, and speak of a tardy and irregular convales- 
cence as characteristic of the disease. In many cases 
it is, indeed, otherwise; and of numerous patients in 
the late epidemic, it may be said, as Hale remarked 
of his. own, "in most instances the patients were out 
of their chambers within a week or ten days from the 
commencement of convalescence." Still, the general 
statement continues to be true, as it is expressed by 
Hirsch: "convalescence is irregular and protracted; 
in spite of good food and regular digestion, emaciation 
and debility are sometimes of long duration." Per- 
sistent headache, neuralgia, convulsions, stiffness of 
the neck or pain in moving it, morbid sensibility of 
some portions of the skin, palpitation of the heart, 
dyspepsia, &c., embarrass the return to health. "It 
is highly probable," as Gallup remarks, "that the in- 



SYMPTOMS. CONVALESCENCE. SEQUELJE. 71 

ternal membranous inflammation is always present 
more or less." 

Sequelae. — These, which are merely the phenomena 
of a retarded and imperfect convalescence, are deserv- 
ing of notice. Deafness, or dullness of hearing, is a 
very frequent consequence of this disease, which has 
been observed by all European and native writers on 
the subject. In our recent epidemic it existed to a 
greater or less extent in sixteen cases. Very often 
the deafness is permanent. Out of twenty-four cases 
observed by Fassett, one half recovered; but three of 
them with entire loss of hearing, and one with partial 
deafness as well as strabismus. Impaired vision pro- 
duced by opacity of the cornea, amaurosis, iritis, &c. 
are occasionally met Vv^ith. Paralysis of one or more 
limbs, and general impairment of muscular power, are 
rare consequences of the disease; and loss of memory, 
and even insanity have sometimes been observed. 
Gordon thus describes the conclusion of a severe 
case: "the man has gradually passed into a state of 
almost organic life; he eats, drinks, and sleeps well; 
he passes solid faeces and urine without giving any 
notice, yet, evidently, not unconsciously ... he seems 
to understand, but he cannot answer ... he can draw 
up his legs and arms, but he cannot use his hands at 
all." Relapses are very far from being uncommon. 
Jackson, &c. state that they occur "in many in- 
stances;" Gallup speaks of them as "very common;" 
Hale notices "several cases;" and in numerous exam- 
ples referred to by Parks, they were met wdth. It is 
remarkable that a large proportion of the last men- 
tioned cases were fatal, while the earlier reporters 



72 EPIDEMIC MENINGITIS. 

remark upon the usual termination in cure of second 
attacks. 

Mortality. — Like all epidemic diseases, meningitis 
presents itself in every possible degree of gravity be- 
tween a slight indisposition and a violent and deadly 
malady. Hirsch has published a table exhibiting the 
mortality of the greater number of epidemics of menin- 
gitis between 1838 and 1865, from which it appears 
that the death rate varied between 75 per cent, and 
20 per cent. So, while the percentage of mortality 
was a little over 61 per cent. (170 deaths in 278 cases) 
during the recent epidemic in Massachusetts, it was 
but 33 per cent. (43 deaths in 130 cases) in the Phila- 
delphia Hospital. It is to be observed, moreover, that 
while ten epidemics, in various places, occurring be- 
tween 1838 and 1848 presented an average mortality 
of 70 per cent., a similar number occurring during the 
decade from 1855 to 1865 give an average mortality of 
about 30 per cent. This remarkable fact would seem 
to indicate a gradual decline of power in the epidemic 
cause. 



FORMS. 

We have several times, in the course of this his- 
tory, referred to the multiplicity of forms assumed 
by the disease we are examining. To those who have 
not studied its records, nor had occasion to behold its 
multiform physiognomy, this peculiarity has been a 
source of innumerable errors and mistakes, the most 
serious of which consists in assimilating it to typhus, 



FORMS. 73 

and in applying to it a system of treatment, which, 
however it may be tolerated, or even necessary, in 
the former disease, is unequivocally mischievous in 
the latter. Forget classified the cases he observed at ^ 
Strasburg as follows: A. Cerebro-spinal : 1. Explosive 
{foudroyante) ; 2. Comatose-convulsive ; 3. Inflamma- 
tory/ ; 4. Typhoid; 5. Neuralgic; 6. Hectic ; 7. Para- 
lytic B. Cerebral: 1. Cephalalgic; 2. Cephalagic- 
delirious; 3. Delirious; 4. Comatose, In the first of 
these divisions three-sevenths belong to the first 
and fourth varieties ; and in the second division 
five-sevenths to the first and second varieties, from 
which it may be inferred that coma in some degree, 
and pain in the head were predominant characters. 
But "there were slight and severe cases; violent 
and hectic forms; cerebral symptoms predominant 
in some, and spinal in others, and the functions of 
the nervous system were variously disturbed." Ames 
arranged his cases in two general divisions, viz : 
The Congestive and The Inflammatory, The Conges- 
tive he subdivided into the Malignant and the Mild. 
Malignant congestive cases were distinguished by pros- 
•tation, coma or delirium, or both; opisthotonos; and a 
pulse of wide range. In Mild congestive cases a good 
degree of strength was preserved; the pulse was 
below 90; there were marked pain in the head and 
tenderness of the spine; and no coma, delirium or 
tension of any except the cervical muscles. The 
Inflammatory cases were, in general, distinguished by 
a temperature of the skin above that of health, and a 
full, firm pulse; but the malignant among them were 
marked by the early occurrence of delirium or coma, 
6 



74 EPIDEMIC MENINGITIS. 

great irregularity of the pulse, opisthotonos, convul- 
sive spasm, strabismus and occasional amaurosis, with 
vomiting and a rapid and fatal course; the grave by a 
slighter development of the same symptoms, except 
coma and delirium; and the mild by a lower grade of 
febrile excitement, the preservation of a good degree 
of strength, a tendency to become chronic, and by the 
absence of coma, drowsiness, delirium, and a cold 
stage. Wunderlich classifies the cases according to 
their relative degrees of severity and the rapidity of 
development of the symptoms, and describes : 1, the 
gravest and most rapidly fatal cases ; 2, the less grave, 
and 3, the lightest cases. The following classification is. 
proposed by Hirsch: 1, the abortive; 2, the explosive 
(m. siderans, the same as m. foudroyante of Tourdes) ; 
3, the intermittent; 4, the typhoid. Of the various 
forms admitted by different authors, and of which we 
have seen examples, we would class together A. The 
Abortive, in which the characteristic phenomena are 
often faintly defined, yet to the practised eye distinc- 
tive. B. The Malignant, in which the symptoms are 
exaggerated, the attack sudden, the course short, and 
the issue fatal. C. The Nervous, including a. the 
ataxic, viz: 1, the delirious; 2, the cephalalgic ; 3, the 
neuralgic; 4, the convulsive; 5, the paralytic; and 6, 
the adynamic, viz : a, the comatose, and h, the typhoid, 
D. The Inflammatory. E. The Intermittent. 

It would not comport with the purpose of this 
essay to describe in detail the several forms of epi- 
demic meningitis. The greater number of them have 
been included in the analysis of symptoms already 
presented. But there are two which perhaps require a 



FORMS. 



75 



few words of separate notice, viz. the Abortive and the 
Intermittent; the one because its real nature may be 
misunderstood; and the other on account of the pecuhar 
circumstances under which it sometimes arises. Abor- 
tive meningitis is observed only during the prevalence 
of the disease in a more characteristic form. Thus, the 
mother of a boy who had died of the fully developed 
disease, " complained of the head and back and limbs, 
and of chilliness, and presented a petechial eruption. 
After active purgative and counter-irritant treatment, 
she was about work on the second day," (Sargent.) 
In Dublin, in 1846, Dr. McDowell remarked, that 
"when inflammation of the membranes of the spinal 
cord was frequent, and in many instances terminated 
fatally, it was observed that the symptoms of excite- 
ment of the spinal cord became developed in the pro- 
gress of ordinary continued fever, without in any way 
tending to produce an unfavorable result." Gaune, 
in 1856, saw nineteen cases of the disease in the Chil- 
dren's Hospital, at Niort. All of them recovered. 
Dr. Burns, of Frankford, Philadelphia, while attend- 
ing patients affected with the disease, was affected 
with headache, and severe pains along the spine and 
in every joint of the body, and a general languid feel- 
ing. Purgation and full doses of sulphate of quinia 
arrested the disorder in two or three days. Kempf, 
during the decline of an epidemic observed "a great 
number of individuals, especially adults, who com- 
plained of headache, malaise, neuralgic pains in vari- 
ous parts of the body, and pain in the nape of the 
neck or other parts of the spine." The case of a 



76 EPIDEMIC MENINGITIS. 

young woman to which we referred upon a previous 
page was of the same nature. 

The intermittent type has been described by Ames 
and other physicians in malarial districts, but it is by 
no means confined to such locahties. According to 
Hirsch, the paroxysms are more or less regular, 
assuming the quotidian or the tertian type; the heat 
of skin, when this is present, the pains, cramps, deli- 
rium, &c. manifesting regular exacerbations and re- 
missions, so that in fatal cases the attack resembles 
pernicious intermittent or remittent fever. Some- 
times the intermissions are manifested during the 
prodromic stage, suggesting a delusive idea of the 
nature of the attack; sometimes the characteristic 
symptoms are intermittent; and sometimes this type 
first manifests itself during the decline of the disease, 
and naturally suggests the suspicion of a relapse. 
This occurrence is not to be confounded with a true 
relapse, of which some notice has already been taken. 

ANATOMICAL CHARACTERS. 

No other epidemic disease presents more definite 
and characteristic lesions, post mortem, than cerebro- 
spinal meningitis. According to its type and its 
duration there never fail to be found some of those 
changes in the membranes or in the substance of the 
great nervous centres which denote the existence of 
inflammation. Congestion of the blood-vessels and 
exudation of serum fibrin or pus beneath the men- 
inges, and difierent degrees of alteration in the nerv- 
ous pulp attest the nature of the process. And since 



ANATOMICAL CHARACTERS. 77 

all or any of these may be found, it follows, that 
however essential the lesions may be to the idea of 
the disease, they do not constitute its exclusive 
manifestation. As death is compatible with the early 
and forming stage of the inflammatory process, as 
well as with its complete evolution, and as the former 
is not always sufficient to account for the fatal issue, 
it is clear, on this ground alone, that, as in other epi- 
demic affections, there is a constitutional element, a 
morbid condition of the blood, which • underlies all of 
the phenomena of the disease, and modifies, more or 
less, its physiognomy, just as the features of a man, 
which are material, assume the most varied expres- 
sions under the influence of the particular emotion or 
passion which at the time may be supreme. 

Exterior. — In most cases cadaveric rigidity is well 
marked and long continued. Burdon-Sanderson states 
that this does not apply to the muscles which had 
been rigid during life. Strong, Jackson, Grallup and 
others have pointed out, and in the same terms, the 
discoloration of the dependent parts of the body which 
takes place after death; the purplish spots on the an- 
terior surface, the redness of the eyes. &;c. disappear 
or grow paler, while large patches of a livid color, or a 
uniform discoloration of the same hue may sometimes 
be observed along the posterior parts of the neck, back, 
nates and thighs. In a case of which we have pub- 
lished the details, the whole body became rapidly 
almost black during two hours before death; but 
afterwards the countenance nearly regained its natu- 
ral hue. It was early noticed that the muscles every- 
where exhibit a deeper shade of color than natural, 



78 EPIDEMIC MENINGITIS. 

which is now said to be of a distinctive brownish red 
shade; but Galhip states that there is no evidence of 
a weakening of their texture. Klebs has, however, 
shown that the rapid and extreme emaciation observed 
in protracted cases of the disease is owing to atrophy 
of the muscular fibres, as well as of the interstitial 
connective tissue. The same observer has also de- 
tected by the microscope a granular deposit between 
the muscular fibres analogous to that which he found 
in typhoid fever and in acute poisoning by phos- 
phorus. 

The Scalp and Cerebral Vessels and Membranes. — 
In the very earliest account published in this country 
(1806) of the anatomical lesions of the disease, it is 
stated by Danielson and Mann that the veins of the brain 
were uncommonly turgid; Bartlett and Wilson repeat 
the statement (1810) ; and Stuart found the blood-ves- 
sels of the dura mater and brain distended. Jackson 
describes the flow of blood on separating the calvarium, 
and of serum on cutting the dura mater, (the latter 
liquid being of a reddish color,) and the great disten- 
sion of the sinuses in cases of rapid death. In Ames' 
examinations the venous congestion was less, but the 
arterial vascularity greater. In some cases this ex- 
tended to the dura mater, in others "the vessels 
lying across the convolutions were uniformly red, 
numerous and large." They were also found in great 
numbers on the walls of the lateral and other ventri- 
cles. In like manner, at the commencement of the 
recent epidemic. Squire said, "the large veins in their 
way to the several sinuses appear remarkably turgid ;" 
and, during its continuance, the same report was 



ANATOMICAL CHARACTERS. 79 

made by all who investigated the subject. So, in 
the European epidemics, from Vieusseux, who de- 
scribes a "sanguineous engorgement of the brain," 
and Mathey, who speaks of the meningeal vessels as 
being "excessively injected," and from Tourdes, who 
states that the sinuses of the dura mater are filled 
with very dense coagula, and the vessels of the pia 
mater distended with blood, to Banks, who uses 
almost the same terms in his description, and Bur- 
don-Sanderson, who found hypersemia of the cranial 
diploe, distended blood-vessels of the dura mater 
whose internal surface was highly colored and mi- 
nutely injected, and excessive congestion of the 
arachnoid covering the hemispheres, — the testimony 
is uniform, that congestion of the brain is an unfail- 
ing accompaniment of the first stage of the disease. 
Next, we find that the transparency of the arachnoid 
is impaired, as it is described, among others, by 
Lidell, Hutchinson, C. M. Clark, and as we have 
always found it when death did not take place in the 
congestive stage. Precisely the same condition is 
reported by European writers, who also, as well as 
our own observers, found the pia mater often adhe- 
rent to the brain, and sometimes so closely that it 
could not be raised without lacerating the cerebral 
substance. This condition is particularly described 
by De Renzi, Tourdes, Gillkrest, Lionnet and others. 
An effusion of serum is an ordinary condition post 
mortem. It is found in the arachnoid cavity and in 
the ventricles. In the former situation it was men- 
tioned by Danielson and Mann. "As soon as the 
dura mater is cut through, a quantity of serous fluid 



80 • EPIDEMIC MENINGITIS. 

commonly escapes from under it. This is not always 
transparent like water, but sometimes quite red 
colored." Gamage says, "a serous fluid was contained 
between the tunica arachnoidea and the pia mater; 
the first membrane being raised from the latter in 
numerous cells." Ames found the effusion in many 
cases, and states that "pus globules were mixed with 
it in every case in which they were sought. In two 
cases the effusion consisted almost entirely of pus." 
Lidell reports a case in w^hich at least six ounces of 
serum were discharged. In another case (Moorman), 
in which death took place on the thirty-fifth day, "on 
attempting to remove the brain, about three pints of 
turbid serum escaped." So, among European authori- 
ties, De Renzi refers to a case in which a pound and 
a half of serum was found between the dura mater 
and the pia mater. Tourdes says, "the arachnoid 
cavity ordinarily contained a small amount of serum; 
occasionally it was dry, or marked by flakes of pus." 
The ventricles are also the seat of an effusion in 
many cases. The first record of the fact is, we 
believe, in Stuart's case, in which "the right lateral 
ventricle contained about a tablespoonful of serum;" 
Jackson says "the lateral ventricles always contain a 
notable quantity of water." Ames met with a purulent 
effusion in several cases; Craig, eight and twelve 
ounces of a limpid fluid in two cases; and Armstrong 
and Clark saw the ventricles distended with sero-pus. 
Serous effusion was observed by Mathey in these cavi- 
ties; and Tourdes found pus in them in more than half 
of his cases, forming sometimes a milky fluid, sometimes 
the true yellow pus of phlegmonous inflammation. 



ANATOMICAL CHARACTERS. 81 

Similar appearances are described by Gillkrest, Wilks, 
Burdon-Sanderson, Hirsch, Klebs and others. The 
last mentioned observer in one case found the lateral 
and the fourth ventricles and the aqueduct of Sylvius 
fully distended by thick yellow pus. It does not follow 
that every milky looking liquid contains pus corpuscles ; 
in many cases the color is derived from exuded fibrin. 
These anatomical conditions would serve to prove 
the essentially inflammatory nature of the process 
in which this disease involves the brain; but a 
more conclusive one remains to be described. This 
is a fihrino-purulent exudation in the meshes of the 
pia mater. Among early American physicians, the 
first who attempted to illustrate the nature of the 
new disease by dissection were Danielson and Mann, 
who, in their essay, which was published in 1806, 
give an account of two post-mortem examinations to 
which reference has already been made. Of the first 
they say, "the dura mater and pia mater, in several 
places, adhered together, and both to the substance 
of the brain;" and of the second, "between the dura 
and pia mater was effused a fluid resembling pus;" 
proving, therefore, that the lesions were those of men- 
ingitis. In 1810, Bartlett and Wilson reported a fatal 
case, in which, among other lesions, was found "an 
extravasation of lymph on the surface of the brain." 
In the same year the report of Jackson and his col- 
leagues contained an account of the lesions, which 
leaves little to be added. After speaking of the con- 
gestion and serous effusion found within the cranium 
"in those who have perished within the space of 
twelve hours from the first invasion," they add, "the 



82 EPIDEMIC MENINGITIS. 

other appearances we are to describe are more con- 
spicuous in proportion to the duration of the disease. 
The tunica arachnoides and the pia mater are remark- 
ably altered in appearance by the effusion of an opaque 
substance between them, which mav be called coao-u- 
lated lymph or semi-purulent lymph," . . . and then, 
speaking of the base of the brain, they remark, '^an 
effusion of coagulated lymph in mass has been wit- 
nessed in the same part." Wilson, again, in 1813, 
described a case presenting "several small depositions 
of lymph on the surface of the brain." In 1818, 
Gamage found in one of his dissections, that "the 
tunica arachnoides seemed to be thickened, and two 
or three small 23ortions of coagulable lymph were dis- 
covered upon its external face." After an interval of 
twenty years the same lesions were found in the epi- 
demic at Montgomery, Alabama. Ames describes an 
abundant deposit of "lymph and pus" upon the ex- 
terior of the brain "under the arachnoid covering of 
the pia mater." At the base of the brain it was most 
abundant about the optic commissure, "indeed, at 
this place, either on the commissure and mamillary 
bodies, or between them and the tuber annulare, it 
was never absent." "It was also found on the corpora 
quadregimina, the medulla oblongata, and around the 
third pair of nerves. The inferior surface of the cere- 
bellum was frequently the seat of this deposit." About 
the same time, in Massachusetts. Sargent found " under 
the cerebral arachnoid, over the upper surface of both 
hemispheres, a whitish deposit, as of purulent matter," 
and "on both sides of the cerebellum a considerable 
deposit of pus and lymph." In 1857, Squire stated that 



ANATOMICAL CHARACTERS. 8o 

in a case narrated by him, "beneath the arachnoid 
membrane was a plentiful effusion of yellowish white 
lymph," and at the base of the brain, " a perfect pool 
of sero-purulent fluid filled the foramen magnum." 
Craig found "lymph of a yellowish and greenish hue" 
upon the convexity and at the base of the brain. 

We have called attention to the relation between 
the brain lesions and the duration of the attack before 
death. It was distinctly pointed out by Jackson and 
his cotemporaries; it is more elaborately presented by 
Upham, in his history of the epidemic at Newborn. 
When death took place within two or three days there 
was commonly opalescence of the membranes, flocculi 
of lymph in the subarachnoid fluid of the convexity 
of the brain, and an exudation of thick yellow lymph 
at the base. After a longer period the exudation was 
more pus like, or more abundant and concrete. In 
two cases, of which the one lasted for tweuty-four 
hours and the other for . twenty-three days, Jewett 
found that these conditions were well contrasted, 
serum predominating in the one and dense lymph in 
the other. Ketchum, also, refers to the stage of the 
disease causing the lesions to vary between congestion 
and exudation; and Githens notices the influence of 
this element in determining differences in the appear- 
ance of the exudation even in a class of cases all of 
which might be termed inflammatory. In point of 
fact there were scarcely any others in the epidemic 
of which he has sketched the history. Similar grades 
of the specific lesion are recognized by European 
writers, as w^e shall presently show. 

It might be inferred from the silence of Yieusseux 



L. 



84 EPIDEMIC MENINGITIS. 

on the subject, that in the Geneva epidemic of 1805 
there were no brain lesions of a distinctly inflamma- 
tory sort, just as it has been too hastily alleged that 
the American epidemic of the same period was an 
idiopathic fever, for no better reasons than that dis- 
sections were not made at all by the first historian of 
the disease, and in some other cases of rapidly fatal 
course vascular engorgement of the encephalon only 
was detected. But we have seen that abundant evi- 
dence of meningeal inflammation in the American 
epidemic existed, and the same is true of the cotem- 
poraneous prevalence of the disease at Geneva; for 
Mathey thus describes the lesions in one case: "the 
meningeal blood-vessels were strongly injected. A 
jelly-like exudation tinged with blood covered the 
surface of the brain. ... On the lower surface of the 
brain and in the ventricles a yellowish, puriform 
matter was found." A full and particular description 
of this lesion is furnished by Tourdes. Sometimes 
the exudation was liquid, and sometimes concrete, 
like butter spread over the surface of the brain. 
Sometimes it was scanty and disposed in streaks 
along the veins; sometimes it was more abundant and 
formed rounded islands of various extent; generally 
it remained superficial, but sometimes, also, penetrated 
between the convolutions. Its consistence varied 
extremely; now, it was like thin pus, and again had 
the aspect and firmness of a false membrane. "It 
existed about equally on the upper and lower surfaces 
of the brain fourteen times; on the upper alone eight 
times, and chiefly six times; at the base alone twice, 
and chiefly nine times; in the ventricles twenty-six 



ANATOMICAL CHARACTERS. 85 

times; on the optic nerves nine times; on the pons 
varoHi four times; on the medulla oblongata three 
times ; on the olfactory nerves twice, and on the cere- 
bellum in nearly every case." Lesions almost iden- 
tical with those just described were found by Gill- 
krest at Gibraltar; Ferrus and others at Petit-Bourg; 
Wilks, in London; Gordon and Banks, in Dublin; 
Gaskoin, in Portugal; and Niemeyer, Hirsch, Burdon- 
Sanderson and others, in Germany. In some cases, 
as in that of Banks, the exudation is confined to the 
base of the brain, while the blood-vessels of the con- 
vexity of the organ are highly congested. The solid, 
semi-solid, or more fluid material constituting the 
exudation is found, on microscopical examination, to 
consist of cell-like bodies imbedded in a transparent 
interstitial substance, or corpuscles and granules float- 
ing freely. Burdon-Sanderson remarks, that "the 
cell-like bodies, although in general resembling pus 
corpuscles, did not present that uniformity of size 
and character which is met with in normal pus. . . . 
The interstitial substance was beset with granules, 
some of which were albuminous, others fatty." Upon 
this point Klebs remarks that very often pus exists 
where it is not visible to the naked eye, and where 
even with the aid of the microscope it is necessary, 
in order to recognize it, that the observer should be 
familiar with its transition forms. Some of these he 
describes as analogous to mucous corpuscles. 

The most recent researches have fully confirmed 
the judgment of Jackson, Upham and other American 
writers, that the physical qualities of the exudation 
depend partly upon the original type of the disease, 



86 EPIDEMIC MENINGITIS. 

and partly upon its duration. In malignant cases death 
occurs before time has sufficed for the full development 
of inflammatory lesions; in those of longer course may 
be found, first of all, turbid serum, then a more or less 
pasty and fibrinous deposit with some admixture of 
pus, and, finally, in cases of long duration the exuda- 
tion becomes tougher, more adherent, and shrivelled. 

The substance of the hrain is generally softened. 
We have met with but one reporter (Hale), who 
describes it as being firmer than natural. Daniel- 
son and Mann state that "the substance of the brain 
was remarkably soft, ofi'ering scarcely any resistance 
to the finger when thrust into it, and the cerebellum 
was found in the same state;" and Bartlett and Wil- 
son say there was "a looseness of texture or disor- 
ganization through the whole substance of the brain." 
Ames found softening in nine out of eleven cases, "in 
some part of the hemispheres, chiefly the cortical, in 
seven cases; in the medulla oblongata and pons 
varolii, in three; in the fornix and septum lucidum, 
in five; in the walls of the third ventricle and canal 
leading to the fourth, and in the infundibulum, in one 
case," &c. It was observed by Craig in several cases, 
and in one of them after an illness of several months 
duration; in another, which terminated fatally on the 
thirty-fifth day, Moorman found the brain softened in 
circumscribed patches; C. M. Clark describes this 
alteration of a high grade in several cases; and Rus- 
sell, with many others, repeats the same testimony. 
As a summary of these lesions and their relation to 
the period of death, the following description by 
Chauffard is instructive. "When death had taken 



m. 



ANATOMICAL CHARACTERS. 87 

place rapidly the upper portions of the brain were 
gorged with blood, the arachnoid already cloudy and 
as if thickened, and a layer of pus upon the corpora 
quadregimina, the optic chiasm, the pons varolii, and 
the anterior portions of the base of the brain; the 
ventricles contained serum, and there was local and 
more or less extensive softening of the spinal cord. 
When death occurred in the second week, there were 
wide strips of false membrane beneath the arachnoid, 
and pus in the ventricles, the walls of which were 
softened; pus abounded at the base of the brain and 
of the cerebellum and in the spinal canal; and the 
spinal marrow itself was softened and sometimes re- 
duced to a mere pulp. When the period of death 
was still later, or very long delayed, the interior sur- 
face of the ventricles, the fornix and septum lucidum 
were reduced to a pultaceous and creamy consistence, 
and in the latter case escaped into the adjoining cavi- 
ties. Portions of the spinal marrow were completely 
destroyed, and in their place was found only a yel- 
lowish liquid, or the empty membranes fell into con- 
tact when it was wanting." It is unnecessary to 
quote in greater detail the statements of European 
writers upon this subject, since they do but reproduce 
the observations of our own physicians. They, how- 
ever, make use of arguments to show that softening 
of the brain in epidemic meningitis is a true anatomical 
lesion and not a cadaveric phenomenon; that in fact it 
arises from a local and persistent oedematous infiltra- 
tion, or from the presence of minute sanguineous 
extravasations. 

Spinal Marrow .^rThe earlier writers whom we 



88 EPIDEMIC MENINGITIS. 

have quoted in the preceding pages do not afford 
much information respecting the anatomical conditions 
of this nervous centre. It was not until the time of 
the publication of Tourdes' Essay that it was habitu- 
ally examined, or that the importance of its lesions 
was appreciated. It may be stated, in general terms, 
that the lesions of the spinal marrow and its mem- 
branes are identical with those of the encephalon. 
The dura mater is often very dark; its blood-vessels 
are engorged; the cavity of the arachnoid is distended, 
and upon incision gives issue to serum, which may be 
clear, or mixed with blood, or simply turbid, while in 
advanced cases a profuse discharge of pus may take 
place from the puncture. C. M. Clark mentions a 
case in which two ounces of pus were collected in 
this manner. The spinal pia mater presents analogous 
varieties in the proportion and distribution of the 
exudation to those found in the brain. They have 
been described, among other native waiters, by Ames, 
Sargent, Squire, Upham, Woodward, Lidell, Arm- 
strong, Craig, Moorman, Russell and Clark, and 
among foreign authors, by Tourdes, Lionnet, Wilks, 
Banks, Burdon-Sanderson, Wagner, Niemeyer and 
Hirsch. The more concrete, and even the purulent 
exudation is not ahvays, nor even usually, diffused 
equally over the cord; often it is limited to the ante- 
rior, and more frequently to the posterior face or to 
some particular region or regions of the organ, the 
larger collections, in the latter case, being connected 
by streaks of lymph or pus. These accumulations 
are usually most abundant at the lower end of the 
cord, and may be found around the roots of the nerves. 



ANATOMICAL CHARACTERS. 89 

Their excess in the lower and posterior portions of 
the cord is attributed by Klebs to the influence of 
gravity. Softening of the spinal marrow appears to 
be less frequent than that of the brain. But Ames 
relates a case in Avhich the cervical portion was soft- 
ened, " the filamentous portion interiorly being re- 
duced to a disorganized pulp." In a case referred to 
by Hirsch, the central canal of the cord was distended 
with pure pus. More complete destructioir sometimes 
occurs, as above described by Klebs and Chauffard. 
Partial and superficial softening of the cervical por- 
tion we have seen repeatedly. 

The Blood. — Next to the great nervous centres. 
the blood presents the most important changes in 
this disease; they are, however, as diverse as the 
lesions affecting the meninges of the brain and spinal 
marrow. But we should here distinguish between 
blood drawn from a vein during life and blood found 
in the body after death, and in both cases between 
the adynamic or malignant and the sthenic or inflam- 
matory types of the disease. Pursuing, at first, the 
chronological order, we find it stated by Arnell, in 
,1811, that "the blood drawn in the early stage ap- 
peared like that of a person in full health; there was 
no unusual buffy coat, neither was the crassamentum 
broken down or destroyed." Fish, also, speaking of 
the same epidemic (1809), says: "two patients were 
bled: one furiously delirious, the other comatose; in 
neither of these did the blood present any uncommon 
appearance. There was no inflammatory buff, nor 
was it dissolved. In one case, in 1807, where the 
eyes were suffused, it had a slight buffy appearance; 

7 



90 EPIDEMIC MENINGITIS. 

in another, in the following year, it was darker, and 
had a larger proportion of serum than usual. The 
twp last-mentioned cases proved fatal in a few hours 
after the patients were bled." Andral noted a very 
marked increase in the fibrin of the blood "in a case 
of cerebro-spinal meningitis, in which, after death, he 
found the spinal marrow surrounded, in its whole ex- 
tent, by a sort of purulent sheath, the pus having in- 
filtrated the pia mater." "At the autopsy," says 
Tourdes, " the blood was remarkable for the abundance 
and toughness of the fibrinous clots." Faure-Villar 
also notes the buflfy coat as characteristic of the 
blood. In 1864, Dr. Ketchum found that "the blood 
had every appearance of blood taken from a patient 
laboring under acute inflammation." Ames states 
that "the blood taken from the arm, and, by cups, 
from the back of the neck," "coagulated with great 
rapidity." "Its color was generally bright — in a few 
cases nearly approaching to that of arterial blood; it 
was seldom buffed: in thirty-seven cases in which its 
appearance was noted it was buffed in only four." 
Analyses were made in four cases, "the blood being 
taken early in the disease from the arm, and was the 
first bleeding in each case. The first was from a 
laboring man, thirty-five years old; the second from 
a boy tw^elve years old, while comatose ; and the two 
others from stout women between thirty and thirty- 
five." I. Fibrin, 6.40; corpuscles, 140.29. 11. Fibrin, 
5.20; corpuscles, 112.79. III. Fibrin, 3.64; corpus- 
cles, 123.45. IV. Fibrin, 4.56; corpuscles, 129.50. 
Tourdes states that "blood drawn from a vein w^as 
rarely buffed; if a buffy coat existed, it was thin, and 



ANATOMICAL CHARACTERS. 91 

generally a mere iridisation upon the surface of the 
clot." Analysis furnished the following results : I. Fi- 
brin, 4.60; corpuscles, 134. II. Fibrin, 3.90; corpus- * 
cles, 155.54. III. Fibrin, 3.70; corpuscles, 143. IV. 
Fibrin, 5.63; corpuscles, 137.84. Maillot gives, as the 
eresult of analysis in six cases, an increase of fibrin to 
six parts, and more, in a thousand. Thus, in not a 
single case in which the blood was analyzed did it 
contain less than three parts of fibrin in one thousand, 
less, that is, than the proportion of this element in 
healthy blood. On the contrary, it perfectly repre- 
sented the condition of the blood in inflammatory .dis- 
eases. These are, we believe, the only reports which 
have been published of a qualitative analysis of the 
blood in epidemic meningitis, and it has been objected 
to them that they were made of blood taken "at a 
second or third venesection, when the proportion of 
fibrin would naturally be increased" (Draper), and 
that "the proportion of fibrin may rapidly increase 
even during venesection" (Klebs). As to the latter 
objection, it appears futile, for it would apply to the 
standard analyses of the blood in other diseases; and as 
to the former, it is not founded in fact, for in most of 
the cases the blood was derived from a first venesec- 
tion. Besides, it would not apply to the proportion 
of the corpuscles, which it is well known diminishes 
rapidly as blood is lost, whereas in the present in- 
stance it shows a decided increase. 

In regard to the condition of the blood after death, 
it has already been stated that Tourdes and others 
found firm fibrinous clots in the heart and large ves- 
sels: but perhaps the greater number of observers 



92 EPIDEMIC MENINGITIS. 

have reported it to be dark and liquid. Such it was 
stated to be in the report of Jackson, and also by 
Lidell, Gerhard, Levick; Niemeyer, Gordon and others, 
and such we found to be in the greater number of 
cases which we examined at the Philadelphia Hos- 
pital. But in two instances, at least, the heart con- 
tained large and very firm fibrinous coagula. Several 
observers have noted a shrivelled or crenated ap- 
pearance of the edges of the blood disks, and an 
irregular distribution of these bodies in the field of 
the microscope instead of the ordinary arrangement 
in rouleaux or piles. 

It is evident, therefore, that when venesection 
has been practised, the blood has uniformly pre- 
sented the characters indicative of inflammation, 
and that in some epidemics, especially in France, 
a similar condition has been observed even after 
death; but that in a large number, probably in a 
majority of fatal cases, the blood, after death, has 
been found dark, and either liquid or else containing 
only soft clots. It follows that the conditions which 
occasion death in a large number of cases include a 
disorganization of the blood. But it is equally true 
that in many others death results from causes inde- 
pendent of such a change, and, as we shall see here- 
after, from a direct interference with the functions of 
the nervous centres which are necessary to life. It 
is probable that post-mortem fluidity of the blood 
exists under two conditions; the one when the epi- 
demic or zymotic cause is so intense from the com- 
mencement of its action as to destroy very rapidly 
the vitality of that fluid; the other when the powers 



CAUSES. 93 

of life are very gradually exhausted by the indirect 
operation of the same influence. In the latter case 
the inflammatory elements of the disease are more or 
less gradually overcome by the prolonged action of 
the peculiar morbid poison which is essential to the 
generation of the disease. 

It is unnecessary to dwell upon the condition 
of the lungs, heart, stomach, intestines, liver, kid- 
neys and spleen, in fatal cases of epidemic menin- 
gitis. These organs present a variety of lesions, 
depending upon the patient's previous health, and 
upon the complications which may arise during the 
fatal attack, but none whatever which properly 
belong to the pathological history of the disease. 
When the joints have been swollen and painful during 
life, pus has been found in them by Levy, Klebs, 
Ottman and others. The lesions which have been 
met with in cases of deafness do not always suffice to 
explain this symptom. It might be supposed that 
the existence of so large a deposit of lymph upon the 
root of the seventh nerve, as is generally found, would 
be habitually attended with more or less impairment 
of hearing. But such is not the case ; and where 
the symptom exists, it must probably be ascribed 
to an alteration of structure in the brain or medulla 
oblongata, or to what has in some instances been de- 
monstrated (Klebs), suppuration of the internal ear. 

CAUSES. 

It may be said, in general terms, that epidemic 
meningitis has occurred in all portions of the tem- 



94 EPIDEMIC MENINGITIS. 

perate zone inhabited by European races and their 
descendants ; in all sorts of localities, among all ranks 
and conditions of society, at all ages, and in both 
sexes, and that it is therefore in the strongest sense 
of the word a pandemic disease. And when the 
statement is added that the disease is not dissemi- 
nated by contagion, it evidently falls into the category 
of the diseases referred to, of whose occurrence no 
other explanation is at present possible than that they 
are directly produced by a specific atmospheric poison. 
Yet there are some peculiarities in the circumstances 
which have attended many of its outbreaks, which, if 
they do not bring the case under the laws which are 
known to regulate the occurrence of other epidemics, 
may at least serve as materials for an induction which 
shall hereafter lead to the law under which this dis- 
ease, also, is generated. The very first particular 
which, in the natural order of causes, we must inquire 
into, illustrates this statement. 

Season. — In the United States epidemics of men- 
ingitis have taken place with great uniformity in the 
winter and spring, as we learn from North, Daniel- 
son, Mann, Fitch, Woodward, Fish, Warren, Gallup 
and Hale, respecting the early occurrences of the dis- 
ease; from Ames, respecting the epidemic of 1848-9, 
and from Squire, Parks, Upham, Ketchum, Arm- 
strong and many others, respecting the last epidemic. 
Indeed we are acquainted with but one exception to 
the rule : the epidemics at Middletown, Connecticut, 
are stated by Miner to have prevailed between the 
last of March and the last of December, 1823, and 
in the summer of 1825. We should have regarded 



CAUSES. 95 

the rule as equally absolute for Europe; but it appears 
to be less so, although the proportion of epidemics in 
summer is comparatively small. In Germany the 
rule has been nearly the same as in the United States; 
but in France, out of 216 local epidemics, 166 occurred 
between December 1 and May 30,. while in the other 
six months of the year there were 50. So in Sweden, 
out of 417 local epidemics, 311 took place in the 
former period and 106 in the latter. 

Weather. — It is evident from the above statement 
that cold and heat have neither of them an absolute 
influence in the causation of this disease, although its 
development is clearly favored by cold. The mode of 
action of this agent may, perhaps, be considered here- 
after. 

Localities, of every sort, high and low, dry and 
moist, those saturated with marsh miasmata, and 
those favored by the pure breezes of mountain dis- 
tricts have been alike invaded by epidemic meningitis ; 
it has passed by large cities reeking with all the cor- 
ruptions of a soil saturated with ordure, and a popu- 
lace grimed with filth, to devastate clean and airy 
villages, and the families of substantial farmers in- 
habiting isolated spots. 

Sex, Age and Occupation. — Instead of destroying 
females and old and infirm people, its victims are 
chosen, in far greater numbers, from among persons 
in the very bloom of youth and early manhood than 
from any other class. It has in many places been 
noticed that the proportion of males attacked is much 
greater than of females j and such is probably the 
general rule. Thus, in Massachusetts, w^here the 



96 EPIDEMIC MENINGITIS. 

female population is greatly in excess, there was a 
preponderance of nearlj^ sixty per cent, of male over 
female patients. In France this difference Avas all 
the more striking, because the first epidemics of men- 
ingitis were so exclusively among males, and especi- 
ally among young military recruits in garrison, that 
its cause was sought in some peculiarity of the sol- 
dier's life, or in some supposed unhealthy condition 
of the military barracks. Yet there are other places, 
as Sweden, and certain towns in Germany, where the 
proportion of deaths among females equalled or even 
exceeded that among males : and in Leipsic, the gar- 
rison remained entirely exempt while the disease 
prevailed among the citizens. In this country there 
were instances which suggested that the conditions 
of military life are peculiarly favorable to the develop- 
ment of the disease. Such was the fatal epidemic in 
1847 in the second regiment of Mississippi Rifles, 
which originated in and was confined to that body, 
during and after great hardships and exposure to in- 
clement weather (Love). During the late civil war, 
while there was at least one military post. Newborn, 
North Carolina, at which the disease raged violently, 
and while it occurred among the soldiers at Gallop's 
Island, in Boston harbor, it never became epidemic 
in the army, although nearly every possible predis- 
posing cause of disease existed within its limits, and 
although this very disease prevailed at the time 
among the civil population. Without going further 
into particulars, it may perhaps be sufficient to state 
that everything proves conclusively the inadequacy 
of the causes which have been considered to deter- 



CAUSES. 97 

mine the development of epidemic meningitis, inde- 
pendently of the concurrence of an unknown specific 
cause. 

Debility. — It has been a favorite theory that what- 
ever causes weaken the system predispose to and 
even excite this disease. Thus we find the following 
passage in North's treatise. "The exciting causes 
are better understood. They are such as immediately 
debilitate the system, as too much fatigue, fear, grief, 
nursing, abuse of stimuli, wetness, cold, and other 
diseases preceding, as the measles and influenza, and 
chincough. Among these, as far as I have observed, 
cold is the most frequent exciting causeT The same 
statement is repeated, substantially, by Fish and by 
Jackson, who subjoins that it is not made "in con- 
formity with general principles," but is "founded on 
the observations of correspondents." Some have 
attributed the recent epidemic to the depressing in- 
fluence of war, forgetting that the disease prevailed 
for several years before war was even so much as ap- 
prehended. A vast array of fiicts exists to demon- 
strate the virulence of the disease in places crowded 
with di. poor and filthy population; but these facts pos- 
sess no special value. They merely illustrate the 
general and familiar proposition that all diseases, and 
especially all epidemic diseases, occasion a greater 
mortality among the hungry, filthy, and vicious, and 
among the feeble and fearful inmates of public estab- 
lishments for the poor, than among the independent, 
industrious, and relativel}^ virtuous classes of society. 
Alongside of such instances, moreover, are hundreds 
of others, like the rural districts and large towns of 



98 EPIDEMIC MENINGITIS. 

our own country, and like the garrisons in France, 
where the victims of the epidemic were remarkable 
for their excellent physical condition and their free- 
dom from mental anxiety. What was true of the 
first epidemic, in Geneva, has everywhere been found 
true. "The disease," says Vieusseux, '^attacked 
people of all ranks at once, poor and rich, in every 
district of the city, in narrow, dirty and crowded 
rooms, and in great houses where clean and well aired 
chambers had but a single occupant." Chauffard, 
speaking of the epidemic at Avignon, in 1840, says: 
" it selected for its attacks only men of from twenty 
to thirty years old, fresh and vigorous young men, 
w^holly exempt from morbid proclivity, and who died, 
almost all of them, in full flesh." The morbid agen- 
cies which have been referred to are permanent in 
all large cities ; and, if they were really efficient, they 
should always determine the occurrence of the dis- 
ease, but they notoriously do not. There are three 
cities, at least, in which all of these causes have 
attained an intensity of virulence unparalleled else- 
where; and yet neither in London, Liverpool nor 
New York has meningitis become epidemic. The 
soil is, indeed, there in which all morbid germs what- 
ever which are adapted to the climate must flourish; 
but the specific germs of this disease have not yet 
been sown in it under conditions appropriate for their 
development. In other words, while we know that a 
certain material poison will generate typhus, and a cer- 
tain other typhoid fever, we are not acquainted with 
the conditions which are essential to the production 
of epidemic meningitis. We may know that some 



CAUSES. 99 

external influences appear to favor, but we know of 
none that are essential to, its generation. 

Contagion. — The contagiousness or non-contagious- 
ness of epidemic diseases is a question which has 
always given rise to differences of opinion, and some- 
times to acrimonious disputes, as the history of yellow 
fever, typhoid fever, cholera, &c. abundantly exhibits. 
If, therefore, a new disease arises, and those who 
have observed it independently of one another agree 
in representing it to be communicable, or non-com- 
municable, by the sick to the well, their judgment 
may be regarded as conclusive. In the present in- 
stance it may be aflirmed that epidemic meningitis 
has been pronounced non-contagious by almost the 
unanimous verdict of competent judges. The few 
dissentients only prove the rule. Let us, as hereto- 
fore, examine the witnesses in chronological order. 

Among American writers w^ho described what they 
sawj the following may be referred to. North de- 
clares categorically, "it is not a contagious disease," 
and again he repeats that such is the opinion of "all 
those physicians who have witnessed its ravages." 
So Haskell, Spooner and Holmes declare, "we cannot 
discover a single instance in which it clearly appears 
that the disease has been communicated from one to 
another by contagion;" and Fiske writes as follows: 
"this I can afiirm, that in all the cases of the spotted 
fever which I have seen, not one could fairly be traced 
to this source." Fish, while asserting that "there 
are facts which go to prove that it is infectious" 
(contagious), admits that "it is not more infectious 
(contagious) than the common typhus (typhoid fever) 



100 EPIDEMIC MENINGITIS. 

or autumnal fevers of our country." which last state- 
ment is an admission that it is not contagious at all. 
And this is the conclusion which the committee of 
the Massachusetts Medical Society tell us, "it is very 
generally agreed" to adopt. Hale furnishes negative 
as well as positive evidence of its non-transmission 
from the sick to the well. Coming down to the recent 
epidemic, we find that among the cases that occurred 
in Stanton Hospital, "no relation by contact could be 
traced" (Lidell). In Vermont, Ketchum was led by 
experience "to conclude that the disease was not 
contagious;" and Holbrook reached the same conclu- 
sion. In Massachusetts, "out of 268 cases" in which 
the question was answered in reference to their origin 
through contagion, "the answers were negative as to 
252." In the epidemic which we observed in the 
Philadelphia Hospital, no evidence whatever of con- 
tagion was afforded. Not a few historians of the 
disease omit, in their reports, all notice of this ques- 
tion, as if it was one that had not been suggested by 
their experience. Neither Ames nor Upham nor 
Squire refers to it. 

In Europe, the first authentic history, by Vieus- 
seux, says " the disease did not extend in the neigh- 
borhood of the sick;" and again, the disease appears 
to depend "upon peculiar atmospheric conditions, and 
not on a contagion communicated from man to man;" 
and, once more, the author proposes to call the dis- 
ease " malignant non-contagious cerebral fever."* In 

* In an excellent paper upon this disease, (New York Medical 
Times, September, 1864, p. 113,) Vieusseux is credited with saying, 
" we do not doubt that this was a malignant contagious fever." This 



CAUSES. 101 

the epidemic of Strasburg, "a study of the facts re- 
sulted adversely to the idea of its spread by contagion" 
(Tourdes); the same conclusion was reached by Ferrus, 
at Petit-Bourg; Wunderlich found "not the slightest 
indication of contagiousness" in the disease at Leipsic; 
nor Burdon-Sanderson, in Dantzic; nor Mannkopf, in 
Berlin. Indeed^ the only writer of authority who has 
contended for the contagiousness of epidemic menin- 
gitis is Boudin, who refers to cases in which the dis- 
ease affected certain garrisons without extending to 
the surrounding civil population, or the soldiers of 
certain barracks while it spared the prisoners confined 
separately within their limits, or vice versa; and other 
cases in which it seems to have accompanied a regi- 
ment to new and healthy quarters, and then attacked 
the recruits there incorporated into the affected regi- 
ment, or the civilians in communication with its mem- 
bers; and again others in which certain barracks were 
occupied by different regiments in succession, and in 
like order were attacked; and finally, cases in which 
the disease spread to physicians, nurses, and other 
attendants upon the sick. The last statement is in 
direct opposition to universal experience; and the 
preceding ones, supposing them to be accurately re- 
ported, only show the existence of some local cause 
capable of determining the development of the dis- 
ease in all who came within its influence; a cause 
susceptible of being transported by healthy men, or 

mis-st'itement is probably due to Boudin, of whose exceptional notions 
we may liave occasion to speak. Mathey, observing the same epidemic 
with Vieasseux, say«, "the idea of contagion, which had alarmed 
many persons, had to be abandoned." 



102 EPIDEMIC MENINGITIS. 

by their camp equipage, from one place where the 
disease existed to another where it had not previously 
occurred. The views of Boudin have failed to satisfy 
and convince all judges who have examined them. 
They fail most where most they need strength, in 
the proof that the disease is ever communicated from 
man to man; and, without that proof, there is no evi- 
dence of contagion. If there is one point in its his- 
tory which is established by the concurrent testimony 
of American and European writers, it is the extreme 
rarity of its attacking the physicians and the nurses 
in attendance upon the sick, and those patients affected 
with other diseases, who occupy the adjoining beds 
in hospital wards. 

PROGNOSIS. 

It will have been observed in the paragraph refer- 
ing to the mortality of this disease that, its issue, in 
general, is extremely uncertain, since the death rate 
varies between widely remote extremes. It was 
there mentioned that the general percentage of mor- 
tality caused by epidemic meningitis had, on the 
whole, been annually declining since the beginning of 
its last appearance. Yet while writing this statement 
we learn that the mortality at the Hardwicke Hos- 
pital, Dublin, in 1866, was not less that eighty per 
cent. In like manner, when it is affirmed that the 
disease occasions a less mortality in the spring than 
in the winter, the proposition should be accepted in 
reference only to the epidemics which having begun 
in midwinter decline in the spring months, and not 



PROGNOSIS. 103 

to those which commence fit the latter season. It 
has frequently been observed that the severest cases 
occur in persons previously in good health. The dis- 
ease certainly exhibits no peculiar tendency to attack 
the delicate and feeble. In the late epidemic at the 
Philadelphia Hospital, nearly ail of the patients were 
"of a vigorous and hardy appearance," and those 
whom we saw at the St. Joseph's Hospital and in 
private practice were most severely attacked in pro- 
portion as they w^ere of the same condition. The 
age of the patients is also an important element in 
prognosis. The mortality is greater in childhood 
than during adult life, and after the age of thirty or 
thirty-five it increases rapidly. The disease is nearly 
always rapid in its development; but suddenness of 
attack or a very short premonitory stage is generally 
an unfavorable sign. This is especially the case when 
the early symptoms are comatose. But of whatever 
nature, violence in these symptoms portends imme- 
diate danger. Thus Niemeyer states that life is most 
endangered during the first four days of the attack. 
Out of thirty-eight deaths, twenty-three took place 
within that period. The conclusions drawn by Parks 
from his careful analysis, are, "first, the prognosis, 
during the first few days, at least, is grave ; secondly, 
after four or five days have elapsed, if fatal symptoms 
be not present, the prospect becomes more hopeful; 
thirdly, the patient is not safe, even in convalescence, 
since there have been instances of fatal relapse." It 
is remarked by Mannkopff, what, indeed, is true of 
many, if not of most other diseases, that a prognosis 
cannot safely be grounded upon individual symptoms. 



104 EPIDEMIC MENINGITIS. 

since the attack may pursue a course diametrically 
opposed to theirs. It is this author's opinion that, on 
the whole, the cerebral are of graver importance than 
the spinal phenomena. In this he is opposed to 
Tourdes, who says that prominent spinal phenomena 
are of grave significance, while cerebral without spinal 
symptoms are favorable. Everything, we should 
judge from our own experience, would depend upon 
the quality of the cerebral disturbance. The greater 
number of rapidly fatal cases present but few and ill- 
defined spinal symptoms. That delirium, even when 
violent, is less dangerous than persistent and deep 
coma cannot be doubted. The latter is, however, by 
no means constant even in fatal cases ; nay, not even in 
such as terminate fatally within a few hours. Its 
absence therefore is not unequivocally favorable. A 
symptom of much more evil augury is a want of per- 
ception of the gravity of the situation, or unconcern 
about its issue. A preternaturally slow pulse is dan- 
gerous, especially if it be compressible, giving a delu- 
sive sensation of fullness and force. Among the 
most unfavorable nervous symptoms are "lively jacti- 
tation, rigid retraction of the head, spasms of other 
than the spinal muscles, general convulsions, exten- 
sive hypersesthesia, dilatation and insensibility of the 
pupil, retention or incontinence of urine, and all cere- 
bral paralyses" (Mannkopf ) , to which may be added 
deep coma, paralysis of the muscles of deglutition, 
and a rapid change of the pupil from a dilated to a 
contracted condition. Coolness of the surface is very 
significant of danger, especially when the skin grows 
purplish by the diffusion of blood beneath it, or even 



PROGNOSIS. 105 

by venous stasis. An eruption of petechise has every- 
where been regarded unfavorably, but less so than 
the condition just named, while the other numerous 
and light colored eruptions incident to the disease are 
rather favorable than otherwise. The more rapidly 
the dark discoloration or eruption is developed the 
more significant it is of peril. Profuse sweats during 
a soporose state; bullae and gangrenous spots; bron- 
chial obstruction with serum or mucus; pneumonia 
and pericarditis, — these are all signs of danger. The 
unfavorable signs drawn from the digestive organs 
are chiefly these: a dry, fissured, or shrivelled and 
pale tongue (Fish), a fuliginous condition of the 
mouth; swelling of the parotids (of minor import- 
ance); obstinate vomiting; profuse diarrhoea, especi- 
ally at an advanced stage of the disease, and persist- 
ent albuminuria. On the other hand, the general 
mildness of the symptoms, a slight loss of strength, a 
moderate degree of pain and muscular stiffness, the 
absence of petechise or vibices, (although in many 
grave epidemics they are of rare occurrence) ; a desire 
for food and the ability to digest it, — these, it need 
scarcely be said, are favorable indications. It will 
be found imprudent too confidently to predict the 
issue of any grave case of the disease. Patients have 
recovered when all hope seemed forbidden, and others 
have died on the sudden accession of nervous symp- 
toms, cerebral or spinal, when the hour of danger 
seemed to have passed away. In other cases, again, 
death has come to the patient's relief after months of 
helpless misery. 



106 EPIDEMIC MENINGITIS. 

DIAGNOSIS. 

The diagnosis of epidemic meningitis may be either 
direct or differential. The former includes the cha- 
racteristic symptoms of the disease. These have 
been already pointed out, buf: it is proper in this 
place to recall them. They depend partly upon a 
special abnormal blood crasis, and partly upon inflam- 
mation of the cerebro-spinal meninges. The various 
proportions in which these elements are commingled 
determine the physiognomy of the disease in individual 
cases. Although not absolutely characteristic, and 
therefore not decisive in an individual case, yet sudden- 
ness of attack and rapidity of development, when they 
have occurred in many cases, suffice to determine the 
character of an epidemic of the disease. The most dis- 
tinctive phenomena are these : acute pain in the head, 
neck, spine and limbs, faintness, vomiting, stiffness 
or spasm of the cervical or spinal muscles, hyperses- 
thesia of the skin, delirium alternating with intelli- 
gence, and merging afterwards into dullness, or coma; 
occasionally convulsive spasms; paralysis of the face 
or of one side of the body. The evidences of blood 
poisoning are, the epidemic prevalence of the disease, 
various eruptions upon the skin (herpes, roseola, pe- 
techias, &c.), ecchymoses, debility out of proportion to 
the evidences of local disease, redness of the eyes, 
foulness of the tongue and mouth, and more or less 
of the other conditions which characterize the typhoid 
state. To these features must be added the rate of 
mortality, which is greater in most epidemics of men- 
ingitis than that of any disease with which it is liable 



DIAGNOSIS. 107 

to be confounded. Some writers draw a distinction 
between epidemic and sporadic meningitis; but if by 
the latter term is intended an idiopathic disease, we 
are obliged to confess our ignorance of its character- 
istics. Meningitis may occur as an effect of traumatic 
causes, and of sunstroke, which is, in fact, a traumatic 
cause, and may be excited by tubercle and other 
morbid deposits in the brain or its membranes, and by 
various other mechanical irritants; but of its occur- 
rence as a primary idiopathic disease no conclusive 
evidence exists. We have never met with an example 
of it; neither has Hirsch, who, while admitting that some 
such cases have been (erroneously) reported, states as a 
proposition, which no one, we imagine, can gainsay, that 
the whole of medical literature does not contain a single 
case of sporadic idiopathic cerebro-spinal meningitis 
with the characteristic sudden onset of the epidemic dis- 
ease. Niemeyer asserts that cases of sporadic men- 
ingitis are almost without exception symptomatic of 
some primary disease or injury; and Klebs, that they 
are extremely rare. Kohler's exhaustive treatise on 
Meningitis Spinalis presents an array of spinal com- 
plications in various diseases which must amaze the 
ordinary observer; for he exhibits them in dentition, 
sunstroke, rheumatism, suppression of habitual dis- 
charges, and suppression and metastasis of eruptions, in 
scrofula, tuberculosis, syphilis, gout, cholera, yellow, 
intermittent and typhoid fevers, in uraemia, cholsemia, 
hydrophobia, and poisonings of various kinds, — yet 
it does not seem to have entered his mind that epi- 
demic meningitis could be regarded as a complica- 
tion or epiphenomenon of any other disease; on the 



108 EPIDEMIC MENINGITIS. 

contrary, he declares expressly that he had no per- 
sonal knowledge whatever of that affection. It is 
but just, however, to say that he admits the occa- 
sional occurrence of sporadic idiopathic cerebro-spinal 
meningitis, and he cites one case out of three or four 
which he himself met with. This case is given 
in detail, and, except in the absence of an eruption, 
is characteristically well defined. But it occurred 
at Halle, in 1857, while a severe epidemic of the dis- 
ease was prevailing in Sweden. Gordon speaks of 
the possibility of confounding epidemic meningitis 
with hysteria. He refers to a few cases which ad- 
vanced treacherously, with slight malaise and vomit- 
ing, lassitude, and occasional pain in the back and 
limbs, rendered very acute by pressure. These 
symptoms, occurring in delicate females, were occa- 
sionally regarded and treated as hysterical. Such 
an error seems hardly excusable. The symptoms 
enumerated would rather suggest neuralgia or rheu- 
matism than hysteria. Fassett states that he saw 
many cases of nervous disorder mistaken for the epi- 
demic disease: "the community were greatly excited 
and alarmed, and every catarrhal or ephemeral fever 
was magnified by their fears into something terrible. 
Ever}^ hysterical girl was at once set to cramping, 
with her head bent backwards, if from any cause she 
had an attack of headache; nor were these actions 
limited to girls, but many nervous ones of the sterner 
sex had ^\mA2.x fearful attacks." 

Typhoid fever has only that degree of resemblance 
to epidemic meningitis which is common to all diseases 
of which the typhoid state is an incident. The con- 



DIAGNOSIS. 



109 



trast was noted by more than one of the earlier 
American historians. It is to be remarked that the 
term typhus employed by them always indicated what 
is now called iyflioid fever ; for they were acquainted 
with no other form of continued fever. The same is 
true of most German authors, even at the present 
time. Many French writers fail to make the dis- 
tinction, also; and English treatises until recently, 
confounded typhus, typhoid, and relapsing fever and 
epidemic meningitis under the common designation 
Fever, In New England, where, as in France, the 
endemic fever is typhoid fever, the last error was not 
generally committed. Hale says, "it has been cus- 
tomary to give the name of typhus to all fevers in 
which prostration and exhaustion are prominent 
symptoms, however variable their character in other 
respects. . . . But if typhus is to be considered as a 
peculiar disease, the fever under consideration was 
not a typhus ; for it did not exhibit the characteristic 
symptoms which belong to that disease. It had not 
the regular approach, nor the uniformity of appear- 
ance of typhus. Its progress was more rapid, its 
features more variable, its changes more abrupt, and 
its termination more sudden." No better summary 
of the symptomatic distinctions between typhoid 
fever and epidemic meningitis has been offered, so 
far as relates to the general course of the two dis- 
eases. Fish pointed out the distinctive characters 
of the two diseases in these terms: "in typhus we 
have an increase of arterial action, a foul tongue, 
bitter taste in the mouth, and loss of appetite, clearly 
indicating a disordered stomach. The intestines also 



110 EPIDEMIC MENINGITIS. 

are deranged; the excretions are altered in quality 
or quantit}^; the temperature is increased, and the 
skin hot and dry; in short, between almost every 
symptom of the two diseases, when they are carefully 
compared, there will be found a material difference." 

T e impression made on Vieusseux by the epidemic 
of Geneva is expressed in these words: "its symp- 
toms differed from those of every form of fever with 
which the physicians of Geneva were acquainted." 
And let it be remarked, that in that epidemic all 
the elements of the disease were present in full 
force; the signs of blood changes and those of 
cerebro-spinal inflammation were equally distinct. 
Tourdes refers to the slow approach of typhoid fever 
and the rapid onset of epidemic meningitis; the ex- 
quisite pain in the head, the neuralgic pains, spinal 
and other, the opisthotonos, convulsions, alternate de- 
lirium or coma and clearness of mind in meningitis con- 
trasting with the hebetude, stupor, or muttering deli- 
rium, and the complete muscular relaxation in typhoid 
fever. The sordes on the tongue, the diarrhoea, the 
meteorism, the intestinal hemorrhage of the latter, in- 
stead of the moist or simply dry tongue and the transient 
vomiting and torpid bowels of the former; high fever 
on the one hand, slight on the other; diffluence of the 
blood and increase in the proportion of fibrin; sup- 
puration within the cranium and lesions of the intes- 
tinal follicles; these as well as the extremely different 
duration of the two affections and the circumstances 
under which they occur, draw a line of distinction so 
broad that none but the blind can fail to see it. Such 
seems, also, to be Niemeyer's opinion, when he says 



DIAGNOSIS. 



Ill 



that the contrast is so clearly defined that it is unne- 
cessary to present parallel pictures of the symptoms 
and course of the two diseases. 

Typhus fever. — Before contrasting typhus fever 
with epidemic meningitis, it is necessary to say a 
word respecting the term "spotted fcA^er," which was 
the ordinary designation of the latter disease in the 
infancy of American medical literature. In this his- 
tory we have constantly made use of the documents 
relating to epidemics of "spotted fever," as if they 
had been more appropriately entitled, and no one 
familiar with the subject will call in question the cor- 
rectness of the method. We have elsewhere shown 
that the epidemic which prevailed in this country from 
1806 to 1815, and was described by Strong, North, 
Hale and others, was in reality a meningitis; and 
Parks has demonstrated the same truth by a detailed 
tabular comparison of the symptoms and lesions in that 
epidemic and the present one. It may also be men- 
tioned that Dr. J. L. Chandler, of St. Albans, Ver- 
mont, who witnessed the first epidemic of meningitis 
in that neighborhood, and the recent occurrence of 
the disease in New England, recognizes the two affec- 
tions as identical. {Boston Med. and Surg. Journal^ 
Ixx, 287.) We should have thought it of less conse- 
quence to rectify the error to which we now refer, 
had it not been committed ]}y so eminent a physician 
as Hirsch, who, in his Monograph on Epidemic Men- 
ingitis, states that "spotted fever" "has nothing in 
common with epidemic meningitis," and refers to a 
chapter in his great work on Epidemics for the proof. 
In that place is to be found a faithful description of 



112 EPIDEMIC MENINGITIS. 

the symptoms of the disease, by Miner, Strong, Fish 
and Kirtknd, from which it is inferred by the author 
that the affection was so peculiar that none analogous 
• to it could be found in the whole range of epidemiologi- 
cal literature. "Unfortunately," he remarks, "the 
reporters have not furnished an account of a single 
post-mortem examination, so that we are reduced to 
conjectures in forming a judgment concerning its 
nature." It is very much to be regretted that the 
distinguished author of this opinion had not been ac- 
quainted with the dissections made from 1806 onward, 
by Danielson and Mann, Bartlett and Wilson, Jack- 
son and others, which we have described elsewhere, 
and which demonstrate conclusively that the "spotted 
fever" of that period was an epidemic meningitis.* 

Considering, now, more particularly, the diagnosis 
between typhus and epidemic meningitis, it may be 
remarked, that by most of the historians of the latter 
disease the distinction is insisted upon in strong terms, 
while others, as Hirsch, do not even notice it. Several, 
however, maintain the identity of the two diseases, 
as will be pointed out hereafter. Among American 
writers upon the subject who recognized the latter 
as a separate and distinct affection, the following may 
be cited. "The malignant fever," snys North, mean- 
ing typhus, "is dissimilar to this disease in the fol- 
lowing respects : the petechise do not generally appear 
in so early a stage of that fever as in this ; that fever 
makes a more regular course in its progress, like other 

* Corson, in his report on the epidemic witnessed by him, says: 
"the disease, as described by Dr. North, though no reference is made 
to its pathology, was clearly a cerebro-spinal meningitis/' 



DIAGNOSIS. 113 

fevers, than this; death does not happen so suddenly 
in that fever as in this ; death happens in that fever 
in seven, fourteen or twenty days; in this, it com- 
monly happens within forty-eight hours from the 
attack; that fever is said to be contagious; this is 
not." Miner says, " we occasionally see the typhus 
petechialis of nosologists, but it differs essentially 
from the spotted fever of New England;" and again, 
"in common language, this epidemic has been gene- 
rally called typhus, though it varies essentially from 
all the fevers which have received that appellation by 
foreign authors." And once more: "this epidemic, 
very obviously was not common typhus, as that term 
is intended to include the nervous and putrid fevers 
of the older authors." Fenner at first mistook the 
disease for typhus, but in a short time he became 
convinced that it was cerebro-spinal meningitis. Dr. 
Gerhard was the first person in Philadelphia to call 
attention to the present epidemic. If any one was 
competent to distinguish another disease from typhus, 
it certainly was he who first established upon a firm 
foundation the diagnosis of the latter disease from 
typhoid fever. It is true that in some points his 
conclusions were erroneous; but he pointed out the 
rapid and irregular course of cerebro-spinal meningitis, 
the absence of calor mordax and the odor peculiar to 
typhus; the great difference in the mortality of the 
two affections ; and the contagiousness of the one, and 
the absence of that quality in the other. In Lidell's 
excellent paper, it is said of the two affections, " both 
of them are blood diseases, and both of them are apt 
to be associated with cutaneous ecchymoses. But 



114 EPIDEMIC MENINGITIS. 

here the resemblance ends. If we examine their 
dinical history with a critical eye, we find that they 
differ from each other as widely as typhoid fever and 
measles." He then alludes to the chief points of dif- 
ference. Epidemic meningitis often runs its course 
in a few hours; tj^phus requires at least several days. 
In the one disease convulsive movements occur, in the 
other not; in one the eruption frequently appears upon 
the first day, in the other not until the end of a week 
or more : " the two diseases are not identical, but 
entirely distinct from each other." So J. S. Jewell 
concludes from a tabular analysis of the phenomena 
of the two diseases, that "they are not identical, but 
really present wide differences;" cerebro-spinal men- 
ingitis is "a disease sui generis, and not a mere form 
of typhus as it has been assumed to be." Woodward, 
also, points out, in detail, the differences between the 
two affections. 

Tourdes, referring to the spinal symptoms said by 
some writers to be present in typhus, remarks that 
epidemic meningitis has more than once been con- 
founded with that disease, and he explains the error 
by a reference to the extremely varied physiog- 
nomy of the former affection. Levy arrives at the 
same conclusion. Lebert objects to those who con- 
found the disease with typhus, that it differs from 
that affection in its anatomical characters, its particular 
symptoms and its general course, and its mortality. 
Niemeyer declares that he is utterly unable to com- 
prehend how certain authors should have mistaken epi- 
demic meningitis for a form of typhus, or have even 



DIAGNOSIS. 115 

supposed it to be a nearly allied affection. It may 
be objected, perhaps, that the continental physicians 
who expressed these opinions were not familiar with 
typhus fever, and were, therefore, incompetent judges 
of the disputed question. Without attaching much 
importance to this objection, we are quite content to 
rest the decision of the question upon the evidence of 
those who were familiar with both diseases, as, for 
instance, the physicians of Ireland. It is true that 
they at first (1849) confounded the new affection 
with other diseases comprised under the vicious de- 
nomination, "fever,'^ while they agreed that they 
never before had met with a similar "fever," and 
they soon learned to term it cerebro-spinal arachnitis 
or meningitis. Quite recently (1867). Stokes found 
that it differed from typhus in the rapidity of its 
course, in the character, mode of appearance, and 
duration of the eruption, and in its cerebro-spinal 
symptoms. Gordon has, also, stated his opinion that 
the marks which distinguish the two diseases have 
been so well laid down by certain American authors 
that it is difficult to confound them. He adds, 
"Murchison, I conceive, has utterly failed in his 
attempt to connect them." In England, also, the 
conclusions of this gentleman have not been accepted, 
and the British Medical Journal maintains that "it is 
impossible even to place the two diseases next each 
other in the nosology, much less to admit their iden- 
tity. ... So complete is the contrast between them, 
that it is scarcely possible to mention a single charac- 
teristic of the former which is also possessed by the 



116 EPIDEMIC MENINGITIS. 

latter." Hirsch goes farther still, and, after comparing 
epidemic meningitis with various diseases, including 
typhus and typhoid fever, in which the typhoid state 
exists, remarks: "the analogies which bind typhoid 
affections together in a single group are extremely 
loose, and hence it becomes all the more difficult to 
include epidemic meningitis Avithin it, particularly 
when it is remembered, that apart from its very 
obscure pathological essence, there is hardly anything 
in its symptoms or lesions which bring it within that 
comprehensive and elastic title typhus!' For our 
own part, having, as already stated, had ample oppor- 
tunities of studying both diseases, and especially 
having witnessed in a large hospital, and during two 
successive winters, an epidemic of each disease, we 
fully adopt the language just quoted as faithfully re- 
presenting what we conceive to be the truth. It is 
very true that without an accurate analysis of the 
symptoms, the diagnosis may sometimes be attended 
with difficulty; but equally true it is that the noso- 
logical table is filled with examples of superficial re- 
semblances between diseases w^hich are radically dif- 
ferent. It is not long since the two great fevers, so 
unlike one another in their causes, phenomena and 
lesions, were regarded as merely casual varieties of 
the same disease. Indeed, epidemic meningitis itself, 
was, as we shall presently see, comprehended, with 
still other affections, in the same nosological group, 
which, with a sublime contempt for the teachings of 
early English and continental physicians, was labelled 
with the vague and inexpressive term Fever, 



DIAGNOSIS. 



117 



TABULAE SUMMARY. 



EPIDRMIC MENINGITIS. 

K pandemic disease. Occurs in places 
remote from one another, and without 
intercommunication. 

Attacks all classes of society. Is 
never primarily developed by squalor 
and deficient ventilation. 

Is not contagious. 

More males than females attacked. 

More young persons than adults. 

Generally occurs in winter. 

Eruptions are wanting in at least 
half of the cases; they occur within 
the first day or two. 

The eruptions are very various, in- 
cluding erythema, roseola, urticaria, 
herpes, &c. Ecchymoses are common. 

Headache acute, agonizing, tensive. 

Delirium often absent; often hys- 
terical, sometimes vivacious, sometimes 
maniacal. Generally begins on the 
first or second day. 

Pulse very often not above the natu- 
ral standard; often preternaturally fre- 
quent or infrequent. Is subject to 
sudden and great variations. 

'* The temperature is lower than that 
recorded in any other typhoid or in- 
flammatory disease." It is also very 
fluctuating. 

The body has no peculiar smell. 

The tongue is generally moist and 
soft; sordes of the teeth, &c. is rare. 

Vomiting, generally of bilious mat- 
ter, is an almost constant and urgent 
symptom, especially in the first stage. 

Pains in the spine and limbs of a 
sharp and lancinating character are 
usual, and evidently neuralgic. 

Tetanic spasms in a very large pro- 
portion of cases and within the first 
two or three days. They are due to 
an inflammatory exudation within the 
spinal canal. 



TYPHUS FEVER. 

Essentially an endemic disease. Al- 
ways due to local causes. Spreads by 
intercommunication only. 

Attacks primarily the poor, filthy, 
and crowded, alone. 

Contagious in a high degree. 

The two sexes equally affected. 

More adults than young persons. 

Epidemics are irrespective of season. 

The eruption is rarely absent, and 
appears between the fourth and the 
seventh day. 

The eruption is uniformly roseolous 
and then petechial. Ecchymoses are 
rare. 

Headache dull and heavy. 

Rarely absent; usually muttering. 
Rarely begins before the end of the 
first week. 

A slow pulse exceedingly rare. Its 
rate is pretty constantly between 90 
and 120. 

The temperature is always more or 
less elevated, and it does not fall until 
the close of the disease. "The skin is 
hot, burning, and pungent to the feel." 

The mouse-like odor of typhus is 
characteristic. 

The tongue is generally dry, hard, 
and brown; and the teeth and gums 
fuliginous. 

Vomiting is rare, and not urgent. 



Pains are dull, heavy, and appa- 
rently muscular. 

Tetanic spasms are unknown in ty- 
phus. Convulsions sometimes occur, 
due to "pyaemia." 



118 EPIDEMIC MENINGITIS. 

EPIDEMIC MENINGITIS. TYPHUS PKVER. 

Cutaneous hypersesthesia is a pro- The sensibility of the skin is gene- 

minent symptom. rally blunted. 

Strabismus common. Rare. 

The eye, if injected, has a light red The blood in the conjunctival vessels 

or pinkish color. has a dark hue. 

The pupils are often unequal. Always equal. 

Deafness often complete and perma- Hardly ever permanent, or attended 

nent. with signs of disorganization of the 

ear. 

Duration very indefinite; but gene- Duration from twelve to fourteen 

rally from four to seven days. days. ' 

Relapses are common. Relapses are rare. 

The blood is often highly fibrinous. The blood is never fibrinous. 

The lesions, unless in the most rapid There are no inflammatory lesions 

cases, consist of a fibrinous or purulent whatever, 
exudation in the meshes of the cerebro- 
spinal pia mater. 

Mortality from 20 to 75 per cent. Mortality from 8 to 40 per cent. 

Finally, and to sum up the elements of this contrast, 
we cannot do better than to quote the following pass- 
age from Dr. Murchison's admirable treatise, in which 
he sets forth the diagnosis of typhus fever from 
"Meningitis." "At the commencement of this cen- 
tury, the symptoms of typhus were referred to cere- 
bral inflammation; and at the present day, typhus is 
not uncommonly designated 'Brain Fever.' The chief 
points of distinction between typhus and inflammation 
of the brain are the following: in inflammation, the 
headache is much more intense, and of a throbbing, 
darting, bursting, or constricting character; in typhus, 
the patient rarely describes it by such terms. The 
delirium of inflammation is more violent and acute 
than that of typhus, and accompanies or alternates 
with the headache; whereas the headache has almost 
always ceased in typhus before the delirium com- 
mences; the loud cries and screams observed in the 



DIAGNOSIS. 119 

delirium of meningitis do not occur in typhus. In 
inflammation there is great intolerance of light and 
sound; but in typhus the senses are obtuse, and deaf- 
ness is more common. In both diseases the face is 
flushed, and the conjunctivae are injected; but in 
typhus the flush is more dusky, and the blood in the 
conjunctival vessels of a darker tint than in inflam- 
mation. In both diseases there may be general convul- 
sions, followed by coma, but typhus never commences 
in this way, as meningitis sometimes does. Strabismus 
and partial palsy are far more common in inflamma- 
tion than in typhus. The physiognomy of meningitis 
is anxious and expressive of pain, or wild and defiant ; 
in typhus it is oftener blank and stupid. In typhus 
there is much more muscular prostration from the 
first than in inflammation. The pulse in inflammation 
is usually firm; in typhus it is soft and compressible. 
Nausea and urgent vomiting are common in inflam- 
mation; rare, in typhus. Lastly, in typhus, there is 
a peculiar eruption appearing about the fourth or fifth 
day." 

In this description the following points, alone, are 
inapplicable to epidemic meningitis, so far as relates 
to its cerebral phenomena. In that disease there is 
not usually "intolerance of light or sound," nor "less 
muscular prostration from the first" than in typhus; 
nor is the pulse "usually firm," because there is asso- 
ciated with the inflammatory element another one 
which is, in different cases, "asthenic" or "adynamic." 
But the reader will probably admit that in every 
other respect the description tallies accurately with 
the picture we have composed from so many portraits 



120 EPIDEMIC MENINGITIS. 

of the disease by different hands. Yet its author 
had not at all in view epidemic meningitis, which he 
had never seen, but either the tubercular, the trau- 
matic, or some other secondary form of meningitis; 
for as a primary idiopathic disease, meningitis, whether 
cerebro or spinal, has not, as we have alread}^ stated, 
been proved to exist. Now, it is very singular that, 
after having furnished so definite and detailed a diag- 
nosis between meningitis and typhus, and after having 
shown, moreover, by the testimony of Reid, Peacock. 
Jenner, Jacquot, Baraillier and Moering, that the 
lesions of typhus are quite independent of inflam- 
matory action. Dr. Murchison should, when at last 
he encountered a few cases of the former disease, 
have regarded them as examples of typhus fever with 
cerebro-spinal symptoms. Such an error can perhaps 
be explained by supposing that these particular cases 
were examples of typhus complicated with epidemic 
meningitis such as have more recently occurred in Dub- 
lin, or that they were simply examples of epidemic 
meningitis, of which numerous cases occurred in Lon- 
don in 1865, '66 and '67. But it is evident that Dr. 
Murchison did not thoroughly appreciate the character- 
istic conditions and phenomena of the two diseases. 
For example; w^hen he asserts, as he has done, that epi- 
demics of meningitis " occur under precisely the same 
circumstances as those in which typhus appears," he 
is in opposition to universal experience. As we have 
shown elsewhere, crowding, filth, hunger, &c. may 
possibly favor the development of this disease, as 
they will that of any epidemic whatever. But these 
causes generate typhus de novo, which is a very differ- 



DIAGNOSIS. 121 

ent thing. Again: the author says, "like typhus it 
has been propagated by contagion," a statement in 
direct conflict with the testimony of every one who 
has witnessed an epidemic of the disease, except 
Boudin, w^hose opinions upon this and other matters 
concerning meningitis have been repudiated by all 
instructed judges. The spastic muscular rigidity of 
epidemic meningitis broadly distinguishes that disease 
from typhus; and Dr. Murchison, in his history of 
the latter disease does not even suggest the possibility 
of such a complication. If, then, as he now informs 
us, "during the last three years" he has "in several 
instances noted strabismus, tetanic contractions of the 
muscles of the limbs, and even opisthotonos," is it not 
probable that they were in reality cases of the epi- 
demic meningitis which then existed in London, or 
of typhus complicated with the latter disease? Dr. 
Murchison also finds that " many American physicians 
admit the close relation of cerebro-spinal meningitis 
to typhus, while some maintain the identity of the 
two diseases." We believe, on the contrary, that 
among American physicians who have had an oppor- 
tunity of studying the two diseases, not one has con- 
founded them. The error has been committed by 
several who did not enjoy this advantage. Dr. Mur- 
chison also adopts the judgment of Dr. Upham, that 
the disease "partakes of the nature of typhus" with 
"a special direction to the meninges of the brain and 
spinal cord." Now, is it the typhous condition to 
which the meningeal inflammation is superadded, or 
is the meningitis the primary affection? Is it an in- 
flammatory typhous affection, or a typhoid inflamma- 
9 



122 EPIDEMIC MENINGITIS. 

tion? To this question but one answer seems admis- 
sible. An inflammatory typhus fever would assuredly 
be a new thing under the sun; but a typhoid inflam- 
mation is one of the most familiar types of disease. 
A typhus fever with a special direction to the cerebro- 
spinal meninges, appears to us a very pathological 
monstrosity. The meningeal inflammation is evidently 
due to quite another element than that which originates 
the typhous symptoms. The one is specific, peculiar, 
and characteristic of this disease alone : the others are 
incidental, non-essential, and common to this disease 
and many other diseases. That which distinguishes 
epidemic meningitis is the concentration of the mor- 
bid action of the disease upon the membranes of the 
nervous centres, and the tendency of that morbid 
action to purulent or plastic exudation. If those who 
die of it in the first stage do not always exhibit in- 
flammatory exudation, it is simply because death 
arrests the inchoate process in its earliest steps. If 
the patient survive for several days and then perishes, 
the characteristic lesions are revealed. But it is not 
so in typhus. No stage, grade, or usual complication 
of that disease was ever attended by cerebro-spinal 
exudation. In the one, exudative matter is detected 
by the microscope first, and then, in due course, by 
the naked eye; in the other, such matter is discover- 
able at no stage and by no method whatever of ex- 
amination. "When the rash of typhus is present," 
says Murchison, "it may always be concluded that 
there is no cerebral inflammation." But there are 
writers upon "typhus" who describe inflammatory 
products beneath the cerebral membranes. Thus, 



DIAGNOSIS. 123 

Roupell states that "in all the cases an affection of 
the membranes of the brain was found, either turges- 
cence of vessels, increased vascularity, effusion of 
serum or pus, or the deposition of lymph, A^arying 
from the thickness of a line to a quantity only suffi- 
cient to render the arachnoid opaque." And South- 
wood Smith says, the arachnoid "is seldom or never 
in a healthy condition. It is always either more 
vascular than natural, or when in this respect un- 
changed, it is altered in structure, being thick, opaque, 
and milky; when in this latter state a gelatinous fluid 
is usually effused beneath it." This author also fur- 
nished a series of cases in which such lesions were 
discovered. Now either Dr. Murchison and all other 
writers who have described typhus fever since its 
diagnosis was established, have fallen into a gross 
error in denying the presence of any such lesions in 
that disease, or the authors from whom we have 
quoted, and others who might be cited to the same 
effect, erred in their diagnosis, and mistook epidemic 
meningitis for typhus fever, or, it is possible, observed 
cases in which the two diseases were associated. Of 
the correctness of the latter alternative there is every 
probability, as well upon the general grounds already 
stated, as upon this, that Smith's Treatise was pub- 
lished in 1829, and in the preceding and following 
years we know that the disease existed in this coun- 
try, and at Sunderland, in England; and that Roupell 
wrote in 1839, when it is certain that epidemic men- 
ingitis prevailed in France, and may have also existed 
in London sporadically. For these reasons, which 
may be summarily stated as follows: 1. That the 



124 EPIDEMIC MENINGITIS. 

causes, symptoms, course, termination and lesions 
are radically unlike in the two affections; and 2. That 
all physicians who have witnessed epidemics of both 
affections, agree in pronouncing them to be different; 
we conclude that typhus fever and epidemic menin- 
gitis are distinct diseases, having, indeed, nothing in 
common but the typhoid state. 

NATURE. 

The preceding considerations, it is believed, will be 
thought sufficient to demonstrate that epidemic menin- 
gitis is not typhus fever, and it therefore only remains 
to show what is its real nature. Upon this question 
we have already several times expressed our opinion, 
which is sustained by the judgment of nearly all who 
have thoroughly investigated the subject. Before 
offering the proof of this statement, it may be amus- 
ing, if not profitable, to cite the theory of one of the 
earliest, if not one of the most instructive, among 
early American writers upon this disease. Dr. Job 
Wilson. This ingenious author discovered that " spot- 
ted fever" is an "influenza!" These are his words: 
"the similarity of the influenza to spotted fever is so 
striking, that had it not been for the accidental ap- 
pearance of spots in some cases, the probabiHty is, 
that the present epidemic would still have continued 
to be called by that name." This author presents a 
tabular abridgment of the symptoms common to the 
two diseases, and concludes that they correspond in 
all the most important particulars, and that he "can 
discern no utility in considering and treating the 



NATURE. 125 

spotted fever and influenza as distinct diseases !" In 
comparison with this the error of confounding typhus 
fever and epidemic meningitis is trivial, indeed, and 
venial. It is remarkable that the only point of real 
analogy between the two affections should have 
escaped an author so possessed by his peculiar and 
original idea. Both diseases are, in the strictest 
sense, pandemic. Produced by no local agencies 
whatever and by no ascertained conditions of the 
atmosphere; arising spontaneously and simultaneously 
at remote points, and being incommunicable by the 
sick to the well, it is impossible to refer them to any 
other than specific atmospheric causes. But here the 
analogy ceases; the characteristic phenomena of the 
two diseases are as different as smallpox and diph- 
theria. It may, perhaps, be truly asserted not only 
that these two affections are, in a true sense pan- 
demic, but that they are the only ones possessing 
that character. All other epidemics are propagated 
more or less, and either directly or indirectly by 
contagion, however much atmospheric conditions may 
favor their diffusion. But epidemic meningitis and 
influenza appear to proceed, primarily and alone, from 
some unknown constituents or conditions of the atmo- 
sphere, or some conjunction of terrestrial causes, the 
nature of w^hich at present eludes our comprehQiision 
altogether, and about which it is an idle waste of 
words to speculate. 

But to return. We shall show that while, as the 
reader has already seen, some few physicians have 
confounded epidemic meningitis with typhus, ignor- 
ing altogether its essential and characteristic local 



126 EPIDEMIC MENINGITIS. 

lesions, and while a small number also regard the dis- 
ease as an inflammation merely, the great majority 
of those whose sagacity enabled them to perceive, 
and whose experience entitled them to judge, agree 
perfect!}^ in assigning to it a compound nature de- 
rived on the one hand from its specific cause, and on 
the other from its local lesions, and proving it to be 
at once a blood disease and a meningeal inflammation. 
Dr. Strong's inferences from the symptoms of the dis- 
ease show that he divined its morbid anatomy: "it is 
evident," he remarks, "from the symptoms, that the 
principal seat of the disease is in the brain and nerves. 
This, we think, appears from the delirium and coma, 
which almost always attend ; from the dilatation and 
contraction of the pupils; the dimness and loss of 
sight; the deprivation of taste; the frequent nausea 
and puking, while the contents of the stomach do not 
appear to be morbidly affected; from the severe pains 
in the head; from the numbness which creeps over 
the surface, and the torpid insensibility w^hich per- 
vades the whole system. It is likewise evident that 
debility and great prostration of vital energy are the 
enemies with which we have to contend." Jackson 
and his colleagues, in their report, arrive at this con- 
clusion: "the disease is fever combined with internal 
inflammation." Fish says, "spotted fever is seated 
in the brain and nerves." Gallup concludes that it 
is "an ataxic fever with a special tendency to inflam- 
mation of the membranes of the brain." Drake is of 
the opinion that it is not a mere fever symptomatic 
of inflammation of the brain; that "there is a lesion 
of innervation made, we know not where, which is 



NATURE. 127 

followed by another of circulation, giving us simul- 
taneously both fever and inflammation." Davis says, 
"I regard the disease as an asthenic inflammation of 
the cerebro-spinal nervous centres with their invest- 
ing membrane, accompanied by a highly septic con- 
dition of the blood." According to Moorman, the 
disease "is essentially an inflammation of the pos- 
terior and basilar portion of the brain and spinal cord, 
and their meninges." These judgments at different 
periods since the first advent of the disease in this 
country, it will be seen, substantially agree. European 
testimony upon this subject is to the same effect, but 
is generally given in a more detailed and precise form. 
Like American authorities, foreign writers give pro- 
minence to the septic or to the inflammatory element 
in their definitions according to the peculiar type of 
the epidemic which they have had to study. Tourdes 
remarks, "although pathological anatomy demonstrates 
an inflammatory element in the disease, it is certain 
that there is something besides; it is a specific inflam- 
mation, a poisoning, a cerebral typhus, produced by 
a specific miasm which has an elective affinity for the 
membranes of the nervous centres." C. Broussais 
adopts the less comprehensive view, and recognizes 
but one element in the disease. He says: "it is an 
ordinary but violent inflammation which differs from 
other acute and fatal phlegmasise, only in its seat." 
In like manner Levy remarks, "its most constant and 
striking characteristic is the tendency to suppura- 
tion . . . and it is not a typhus, whatever analogies 
with that disease it may present." 

The physicians of Dublin during the recent epi- 



128 EPIDEMIC MENINGITIS. 

demic agreed that it was a very different disease 
from typhus, while some laid more stress upon its 
inflammatory and others upon its septic element. 
Among others, Dr. Law, w^ho had had peculiarly 
favorable opportunities for observation, "looked upon 
it, no matter how^ modified, as cerebro-spinal arach- 
nitis;" Dr. Kennedy held it to be both a blood dig- 
ease and an inflammation, the latter being less essen- 
tial than the former; Dr. Hayden recognized the same 
elements in the disease, but maintained, on the con- 
trary, that the cerebro-spinal inflammation is at least 
as original and primary as the disorder of the blood; 
Dr. Moore "thought physiology and pathology must 
lead us to view this disease as essentially of a cerebro- 
spinal character;" Dr. Banks "believed the disease 
w^as a blood disease, and that the greater number of 
cases were cerebro-spinal arachnitis." The same 
opinions, substantially, were expressed by Dr. Stokes. 
It is, says Wunderlich, "a disease, sui generis, and is 
not to be regarded merely as the expression and re- 
presentative of internal local lesions." The symptoms, 
he further remarks, are not in exact proportion to the 
lesions, nor are they all explicable by them. Hence 
it is necessary to admit a constitutional as w^ell as a 
local element of the disease, which often, indeed, be- 
comes the predominant one, just as in eruptive and 
typhoid fevers, in diphtheria, dysentery, erysipelas, 
&c. the most fatal cases are those precisely in which 
death occurs at so early a stage, through the violence 
of the constitutional element, that the local lesion re- 
mains incomplete or is entirely undeveloped. Hence, 
too, in the disease under consideration, its physiog- 



NATURE. 129 

nomy varies with the predominance of the blood 
chansres on the one hand, or of the menins^eal lesions 
upon the other; and there is every probability that 
in this, as in most other epidemic diseases, the mor- 
bid cause exerts its primary action upon the blood. 
Hirsch concludes that the disease is 8ui generis^ dif- 
ferent from all others etiologically and pathologically. 
It has no local origin nor geographical limits, is due 
to no local causes, nor any appreciable conditions 
whatever, and therefore it can only be due to a 
specific cause. It differs from many other epidemic 
diseases by the concentration of its poison upon a 
single organ, while many phenomena distinctly indi- 
cate its operation throughout the whole economy, 
especially the petechial and other eruptions, but most 
of all those rapid cases which terminate fatally within 
a few hours. This is also, substantially, the judgment 
of Niemeyer and Mannkopf. Klebs illustrates his 
opinion by suggesting the analogy of epidemic men- 
ingitis and of typhoid pneumonia, in which also, there 
is a predominant typhoid type and a local inflamma- 
tion. The same may be said of epidemic dysentery. 
Klebs remarks further, that it may be questioned 
whether the general disorder of the system proceeds 
from the local affection, or w^hether both are not direct 
effects of the unknown epidemic cause. Having ascer- 
tained that even when inflammatory lesions are invi- 
sible to the naked eye, they may nevertheless be de- 
tected by the microscope, he concludes that these 
lesions are essential to tho disease and are direct and 
primary effects of the action of the morbid cause. 
Apart from this we should still so regard them, inas- 



130 EPIDEMIC MENINGITIS. 

much as they are uniformly, and even visibly, present 
if death has not intervened to prevent their develop- 
ment. So constant a lesion cannot be accidental, and 
must be essential. The inflammatory element and 
the septic element are both necessary to constitute 
the disease ; either may be in excess and overshadow 
the other. According to the relative predominance 
of one or the other, the disease assumes more of a 
typhoid or more of an inflammatory type, and it is 
this diversity in its physiognomy which has led to 
such opposite doctrines in regard to its nature and its 
nosological affinities. 

NAME OF THE DISEASE. 

Gallup commences the chapter " On Spotted Fever," 
in his work on Epidemics, with these words : " Having 
little anxiety what name is attached to any particular 
habit of disease, provided that the name does not in- 
fluence the treatment, we shall not dispute about this, 
and shall be as willing to continue it as any other; 
and more so at this time, as everybody knows what 
is meant by it." Here are two bad reasons, at least, 
for an erroneous conclusion. Words are things; and 
few indeed are the physicians independent enough to 
treat a disease by one method, when its accepted 
name clearly indicates the decision of the profession 
that an opposite method is alone appropriate. If 
everybody knew what is meant by "spotted fever," 
many papers, including Dr. Gallup's and the present 
one, might have. remained unwritten, and the learned 
physicians of Dublin, in college assembled, would not 



NAME OF THE DISEASE. 131 

have proposed at least eight different names for the 
existing epidemic* It is well known that the disease 
is popularly called "spotted fever," and that a great 
many physicians have, perhaps thoughtlessly, adopted 
the popular name. It is not so well known, or recol- 
lected, that the epithet petechial was early used by 
physicians in this country, although the term was 
really less accurate than the vulgar one, inasmuch as 
purpurous spots were more frequent than petechise. 
North himself, in 1809, designated the disease as 
"typhus petechialis, or the malignant spotted fever." 
But in 1811, he writes, "this symptom (petechise) 
does not occur so often as the name which this dis- 
ease has obtained would lead one to expect." Per- 
haps, also, he discovered that the name had been 
already appropriated to quite another affection by 
Huxham and Hoffmann, and many others after them, 
viz. petechial typhus with which Irish emigration, 
and some local epidemics, have made the physicians 
of our Atlantic seaports familiar. Strong had the 
same experience as North, and guided by it made a 
similar statement. "So frequent, indeed," he re- 
marks, "was this species of hemorrhage (petechial) 
during the first season in which the disease prevailed, 
that it was considered one of its most striking cha- 
racteristics, and gave rise to the name petechial, or 
SPOTTED FEVER, which has been very generally though 

* The following are the names referred to. "Malignant purpuric 
fever ^' (Stokes); " Cerebro-spinal fever," and '"Fever with cerebro- 
spinal meningitis '^ (Gordon): "Febris nigra" (Lyons); "Malignant 
purpura" (McSwinney); "Pestilential purpura" (Banks); "'Black 
death" (A. Smith); and "Cerebro-spinal meningitis" (Hughes, Law, 
Banks, Ilayden, Moore, Bennett, and others). 



132 EPIDEMIC MENINGITIS. 

very improperly applied to the disease." In 1808, 
W. Foot wrote, "some have given it (but improperly) 
the name of spoited fever T In 1810, the committee 
of the Massachusetts Medical Society remarked that 
"the name of spotted or petechial fever has been con- 
sidered improper by most medical men who have had 
occasion to remark upon the subject." In 1812, a 
writer in the New England Journal, referring to the 
same subject, remarks: the disease "being only occa- 
sionally accompanied with spots, it seems somewhat 
out of rule to name it by a character which is so little 
constant." In the following year, and in the same 
journal, another writer calls attention to the rare 
occurrence of petechise, and remarks that "the em- 
ployment of this appearance to designate the disease, 
must, therefore, be considered very unfortunate." In 
the same journal, also, of 1814, we find that "w^ell 
informed practitioners of all descriptions are dissatis- 
fied with the name;" and again: "the discontinuance 
of the name ^spotted fever' is not merely desirable 
for the sake of correctness of speech, spots being 
neither j»^cz^/z<2r to, nor constant in this complaint; but 
where this name prevails, the frequent absence of 
spots leads to doubts as to the existence of the dis- 
ease." So Fish, in 1815, remarked, "the name by 
which the disease is known is incorrect; because, 
strictly speaking, it is not a fever, and it is rarely 
attended with petechise or spots." In 1822, Miner 
expressed himself strongly upon the subject, in these 
words: "it is quite unfortunate that a single symp- 
tom (petechise), and one, too, w^hich is wanting in a 
great majority of the cases, should have been seized 



NAME OF THE DISEASE. 133 

upon, to give ihe odious mid deceptive name of spotted 
fever, as that name has been applied by European 
writers to a very different kind of fever. Indeed, 
petechise may appear in diseases of a very different 
character; and often in purpura hemorrhagica, sea- 
scurvy, and other chronic complaints which are unat- 
tended with fever." Finally, in 1849, when Sargent 
published an account of cerebro-spinal meningitis, as 
it occurred in Millbury, Massachusetts, he referred 
to the history of the epidemic of 1812, and to the 
name it received in these words: "they gave the 
name (spotted fever) to the epidemic only because 
its lesion was not known, and the name was pic- 
turesque." 

When American medical writers of the present 
day designate epidemic meningitis as "petechial" or 
"spotted" fever, although these terms were con- 
demned by the first historians of the disease in this 
country as inappropriate, and although later experi- 
ence and the revelations of morbid anatomy have 
alike demonstrated them to be incorrect, we are un- 
willingly led to conclude that either they are unac- 
quainted with the history of the disease, or that they 
have not attentively studied its phenomena, or tho- 
roughly investigated the evidences of its nature. In 
Europe this error has rarely been committed. With 
few exceptions, all who have written upon the sub- 
ject, whether English, Irish, German or French 
authors, are substantially agreed that the proper title 
of the disease is epidemic meningitis, or cerebrospinal 
meningitis. Even among the physicians of Dublin, 
those only who were least familiar with its phenomena 



134 EPIDEMIC MENINGITIS. 

indulged in that luxury of nomenclature to which 
allusion has already been made. In those of the 
foregoing pages which relate to the general history 
and description of the disease, as well as in those 
more particularly devoted to determining its nature 
and its proper name, it is hoped that the reader will 
find satisfactory reasons for giving it the only title 
which usage, authority and sound logic approve. 

TREATMENT. 

The difficulties involved in the questions which 
have hitherto been discussed in this essay, and which 
refer exclusively to the history, phenomena and 
nature of epidemic meningitis, are trifling in compari- 
son with those that relate to the cure of the disease. 
These are partly inherent in the general subject of 
therapeutics, in which no problem whatever is sus- 
ceptible of a categorical and permanent solution. 
They depend still more upon the epidemic nature of 
the disease in question; for this nature gives to dis- 
eases a much greater diversity of type and tendency 
than they ever assume in their sporadic condition. 
These difficulties are further multiplied by occurring 
in a disease which stands alone in all other respects ; 
whose causes, phenomena and lesions, in a word, 
whose laws are specific, and whose varieties of type 
are as infinite as can be formed by the combination, 
in constantly varying proportion, of a special disease 
of the blood deranging the molecular actions of the 
economy, and an inflammation of the cerebro-spinal 
meninges, and even of the substance itself of the great 



TREATMENT. 135 

nervous centres. These reasons are sufficient to 
account for the divergent, and often opposite methods 
of treatment which have been adopted and recom- 
mended by physicians of equal sagacity, at different 
times and places. By some a most actively stimu- 
lating and tonic method has been pursued, because 
the disease, in their experience, was one of utter 
prostration from the commencement, a " sinking 
typhus " as they expressively termed it. To others 
active inflammation of the brain and spinal marrow, 
denoted by excruciating pain and tetanoid phenomena, 
appeared to call for the use of vigorous antiphlogistic 
measures, or the constitutional operation of mercury. 
Others, still, discerned an imperative indication for 
the administration of large doses of opium to coun- 
teract the spasmodic phenomena and the severity of 
the neuralgic and cerebral pain which are so distinc- 
tive of the complaint, without particular regard to the 
physical causes of the pain itself These are the 
most prominent and characteristically different methods 
used in the treatment of epidemic meningitis; and 
while it seems probable that each may have been 
successful, and therefore right, as a general method 
applicable to one or another of the several types 
assumed by the disease, it is equally certain that a 
uniform, or even a general success can be claimed for 
neither of them. We are too apt to think, or at least 
to speak as if we thought that all cases of an acute 
disease are curable, and that the rate of its mortality 
is also a measure of our own ignorance or inefficiency. 
In this we greatly err. Our art is as little respon- 
sible for the enormous mortality of epidemic menin- 



136 



EPIDEMIC MENINGITIS. 



gitis as it is for that of cancer or tuberculosisj or for 
the rapidly fatal issue of certain wounds and other 
injuries. In epidemic meningitis, as in other acute, 
and especially epidemic diseases, many cases are fatal 
from the outset; the first symptoms of the attack are 
the first phenomena of death. On the other hand, 
many are so slight as scarcely to require medicinal 
interference for their cure. But the event of many 
others is determined by the appropriateness and the 
opportuneness of the treatment, of which we shall 
now attempt to furnish the elements; but their suc- 
cessful application depends upon the sagacity of the 
physician. 

Antiphlogistic Method — Emetics. — All whose ex- 
perience entitles their judgment to respect insist upon 
the necessity of the early application of remedies. 
The forming stage of diseases is a precious and a 
fleeting opportunity for their cure. The organic ele- 
ments which are then crystallizing, or, if the figure 
seem more apt, germinating, and assuming a determi- 
nate and permanent form, may at that stage some- 
times be dispersed by a judiciously vigorous treat- 
ment. Hence it is that emetics have always, until 
the present dainty epoch of therapeutics, been held 
to be useful, if not indispensable, remedies in the first 
stage of nearly all diseases. It was so during the 
epidemic of Geneva. Yieusseux attributes the mor- 
tality which then occurred, in great part to the neglect 
of evacuants used to combat the earliest symptoms of 
the attack. ^'The first, the principal, and often the 
only remedy" which he found necessary, was tartar 
emetic, in the dose of half a grain every ten minutes. 



TREATMENT. ANTIPHLOGISTIC METHOD. 137 

or sufficient to produce full and free vomiting. This 
dose was repeated five or six times, or oftener, accord- 
ing to its effects. Sometimes it arrested the vomiting, 
the fever, and the pain in the head immediately, and 
was generally sufficient for the cure. It is to be re- 
marked that this treatment was applied to an epidemic 
which presented in a marked degree those purpurous 
spots which suggested the vulgar name of "spotted 
fever." Yet, if we are not mistaken, Vieusseux is 
the only writer by whom it is recommended. Strong 
and North condemn all evacuations until the energy 
of the system has been in some degree restored. 
Gallup admits that emetics have been used sometimes 
successfully, but that, after all, their good effects are 
doubtful. Hale, at the commencement, employed 
this method, but was disappointed in its efPects, and 
soon omitted it. But where the stomach was mani- 
festly deranged "previous to the attack of fever," 
it sometimes arrested the progress of the disease. 
Tartar emetic and ipecacuanha together were pre- 
scribed by Hale. Miner condemned emetics as liable 
to produce uncontrollable vomiting, and therefore 
dangerous exhaustion. In Europe this method has, 
with the exception stated, been but little employed, 
and is generally disapproved. Yet Tourdes prescribed 
full doses of tartar emetic to twelve patients among 
those most dangerously ill, and near the commence- 
ment of the attack. Four of them recovered, and 
two seemed to owe their improvement to the medi- 
cine. We need not, therefore, absolutely shrink from 
using tartar emetic or ipecacuanha, or warm bitter 

infusions during the primary period of the disease, 
10 



138 EPIDEMIC MENINGITIS. 

according to the strength of the patient, hoping thereby 
to scatter the congestion which tends to produce exu- 
datiye inflammation of the cerebro-spinal membranes, 
and to aid in eliminating the morbid material of the 
disease. 

Purgatives. — Of these medicines little need be 
said. Experience has nothing in their favor to pre- 
sent, and there is no indication founded on analogy 
which is of sufficient weight to be regarded. As 
Miner remarks, "it is as safe to leave a wounded 
artery to nature, as in this disease to administer a 
cathartic, without directing its free operation to be 
indantly checked by opium. . . . One patient was seen, 
that sunk irretrievably, by a single operation of an 
enema." Except upon the dangerous ground that a 
remedy must be directly addressed to every symp- 
tom, there is no room for cathartics in this disease. 
The constipation, if any exists, yields usually without 
purgative medicine, and is, in fact, and as far as it 
goes, a sign of health rather than of disease. 

Depletion.— If a judgment were now, for the first 
time, to be pronounced upon the value of depletion 
in this disease, it would certainly be unfavorable j 
but a suspicion might fairly be entertained that it had 
been biased by the doctrines, or prejudices, whichever 
they may be, of the present day. But when we look 
at the history of epidemic meningitis, which includes 
a period when blood-letting was a cardinal point of 
doctrine in the orthodox creed, we still find that the 
weight of authority was opposed to its use. During 
the first epidemic in this country, Strong informs us, 
some persons had recourse to the lancet, hoping to 



TEEATMENT.^DEPLETION. 139 

relieve the patients from the depression supposed to 
depend upon congestion; but upon finding that "the 
pulse, instead of rising, sunk still lower after a mode- 
rate bleeding, they laid aside their lancets." Foot, 
North, Hale, Jackson and Miner, among the early 
American authorities, agree in condemning it; Gallup, 
alone, advocated depletion on the ground of its reliev- 
ing internal congestion, allowing the heart to act more 
freely, and favoring diaphoresis. He insisted that it 
was "often necessary and sometimes indispensable." 
The " grounds " just stated can only afford a founda- 
tion for practice, in so far as the practice is justified 
by experience; in that case they are superfluous, or 
are merely useful in enabling us to generalize them 
as facts along with other similar facts. The testimony 
of Ames upon this question is so circumstantial and 
decided that we transcribe it almost entire, only re- 
minding the reader that the epidemic to w^hich it 
relates was one in which neither ecchymoses nor 
other evidences of blood dyscrasia w^ere prominent, 
but in which, on the contrary, cerebro-spinal inflam- 
matory lesions attained their fullest development. 
Blood-letting "was employed, wdth few exceptions, 
only near the beginning of the attack. It was used 
frequently, and boldly, without regard to the state of 
the circulation, that is, as readily and freely in the 
congestive as in the inflammatory forms. The quan- 
tity taken at one bleeding, or at several in quick suc- 
cession, w\as sometimes very great — on one occasion, 
the quantity ascertaiiied to have been taken at a 
single bleeding was forty-eight, and on another forty- 
four and a half ounces. In many other instances 



140 EPIDEMIC MENINGITIS. 

bleedings equally large, or larger than these were 
had, but the precise quantities were not ascertained. 
In one case which I visited in consultation, eighty 
ounces were taken at several bleedings within twenty- 
four hours. In a case treated by Dr. Boling, a female, 
fifteen years old, w^ith the notes of which I have been 
furnished, there was taken by cups from the neck and 
occiput forty-eight ounces, and from the arm twenty- 
six ounces, all within eighteen hours. These are 
extreme quantities ; in the greater number — the quan- 
tity taken altogether from adults in one day, varied 
from fourteen to forty ounces — in twenty-six cases, 
the average was found to be thirty ounces. The 
effects of blood-letting were not so satisfactory as 
might have been expected. Within my own obser- 
vation they were never promptly decisive for much 
good or evil; the pulse in congestive cases rarely ever 
filled up, or became regular from it; in some instances 
it became quicker and more feeble during, or soon 
after rather a small bleeding taken on the first day of 
the attack. In the inflammatory form, also, the same 
thing was occasionally observed, though in this form 
an improved state of the pulse was more frequently 
the immediate consequence of the loss of blood. The 
most common sensible effect, however, was relief to 
the cephalagia, but even this advantage was not always 
gained. In the case referred to above, of the loss of 
forty-four and a half ounces at one bleeding, the pain 
which was distressing to the last degree, was hardly 
at all relieved, although the pulse was enfeebled by 
it, and the face made pale at the time, and for several 
days afterwards. In another instance in whicJi the 



TREATMENT. DEPLETION. 141 

symptoms, besides the cephalalgia, seemed urgently 
to call for this remedy, no relief whatever was ob- 
tained from it, notwithstanding that both the pulse 
and skin were greatly affected by it, as in the other 
case just mentioned, and a tendency to syncope was 
much complained of during and for some time after 
the abstraction of blood. Nevertheless, prompt and 
free bleeding in the early stages, and the earlier it 
seemed the better, must, I think, have been of con- 
siderable advantage in this epidemic in both the con- 
gestive and inflammatory forms. Though the benefit 
was neither immediate nor decisive, yet I cannot doubt 
in surveying the whole ground, that time at least was 
gained by it for other remedies more obviously bene- 
ficial to produce their effects. It is certainly true, 
however, that the impression of the physicians gene- 
rally here in regard to bleeding, even in the bold, and 
I may be allowed to add, the judicious manner in 
which it was applied, was one of disappointment." 

In Europe, among others who adopt the same 
views, may be mentioned De Renzi, who says, "we 
have little reason to be pleased with its effects. Em- 
ployed the first day of the disease with great modera- 
tion, and in young and robust patients, it to some 
extent moderated the severity of the symptoms, but 
not to a very gratifying degree." Tourdes tested to 
the fullest extent the treatment of this disease by 
depletion; his testimony, in an abridged form, we 
subjoin. "From one to four times each patient was 
bled to the extent of from eight to sixteen ounces; 
from fifty to two hundred leeches were applied to the 
temples, the mastoid processes, &c." Now, "what 



142 EPIDEMIC MENINGITIS. 

was the influence of this antiphlogistic treatment? the 
statistical results furnish a peremptory reply: the 
mortality nearly reached the proportion of two-thirds. 
Assuredly such a result leaves no doubt whatever in 
regard to the general uselessness of the depletory 
method." This is certainly a very mild judicial sen- 
tence. It follows from the reports of different French 
physicians, whose testimony is collected by Boudin, 
that nearly all formed an unfavorable opinion of the 
curative power of depletion. Mottet asserts that de- 
pletion, whether general or local, is always mischiev- 
ous. Lefevre, Faure, Besseron, Corbin, Maillot and 
Laveran, pronounce it to be either useless or injurious. 
Faure Villars lost 42 patients out of 101 treated by 
the antiphlogistic method. About four pints of blood 
were taken from each. Rollet claims to have cured 
hf an equally sanguinary practice all of fourteen 
cases, in which he judged the membranes only of the 
cerebro-spinal axis were inflamed, and six out of ten 
cases in which he diagnosticated a simultaneous in- 
flammation of the nervous centres. Forget, Mouchet, 
Magail and others, equalled, if they did not exceed 
these physicians in the lavish expenditure of blood, 
which, fortunately for them, was not their own. 

It is not easy to distinguish between the relative 
values assigned by experience to general and to local 
depletion, for in the greater number of reports both 
measures were conjoined. Yet the impression seems 
to have been that the latter is less open to objection 
than the former. In the epidemic at Rastatt, Nie- 
meyer found local depletion so efficient in relieving 
pain, provided that it was early resorted to, that he 



TREATMENT. COLD TO THE HEAD AND SPINE. 143 

attributes to it the most useful influence. But others 
have made the observation, which Ave are able to 
confirm* that in young persons, and especially in chil- 
dren, the least abstraction of blood may be followed 
by dangerous exhaustion. Our own observation 
would lead us to conclude that in the more sthenic 
cases, scarified cups applied to the nape of the neck 
and along the cervical vertebrae are of essential ser- 
vice in mitigating, and generally, indeed, in wholly 
removing the neuralgic pains which form so promi- 
nent and so severe a symptom in many cases of the 
disease. When any abstraction of blood appears to 
be contraindicated by the patient's debility, dry cups 
afford him signal relief, and render the effects of vesi- 
cation more prompt and complete. 

Cold to the Head and Spine would almost instinct- 
ively be employed by any physician acquainted with 
the pathological changes going on in the nervous cen- 
tres in this disease, or even by any one who witnessed 
the patients' complaints of pain in these parts. In the 
Massachusetts Society Report of 1810, we read, "cold 
water, snow and ice have been applied to the head. 
These applications have been made when there was 
violent pain in that part with heat and flashed face, 
and when there was violent delirium. The cold ap- 
plications have in these cases afforded great comfort 
to the patient, and have mitigated or removed those 
very important symptoms. Sulphuric ether dropped 
on the head and allowed to evaporate has produced 
similar good effects." Rollet recommends that when- 
ever the head is warm or there is a tendency to drow- 
siness a bladder containing pounded ice with bran 



144 EPIDEMIC MENINGITIS. 

should be applied. Niemeyer thinks highly of such 
applications in the first stage, and especially of cold 
effusions upon the head while the patient is in a warm 
bath. Sanderson saw beneficial effects arising from 
ice to the head and to the spine during the forming 
stage. Mannkopf strongly recommends cold applica- 
tions to the head; and Hirsch pronounces them the 
best of all the antiphlogistic remedies employed in 
this disease. To these judgments w^e 'substantially 
subscribe; but we believe that the value of the remedy 
is almost entirely restricted to the forming stage of 
the attack, and w^hile the pain in the head is most in- 
tense. Its soothing influence is then very marked. 
Heat of head is not an essential indication; for even 
in the most violent cases its degree is rarely extreme, 
'i and it is often entirely wanting. Pain calls more dis- 

tinctly for the remedy, but, w^hen this symptom lias 
subsided, the application is more annoying than grate- 
ful to the patient. The best method of applying cold 
is that already mentioned, i. e. a bladder containing 
pounded ice mixed with bran. But cold affusions are 
also very valuable, especially in children, whose thin 
skulls permit the prompt and full operation of the 
remedy. A long rubber bag filled with iced water 
is sometimes fastened round the head. Its shape, 
color and projecting brass screws give it a revolting 
aspect, and its weight renders it oppressive. 

External Stimulants. — Blisters, it will readily be 
supposed, have been employed whenever the evidences 
of active inflammation within the cranium and spine 
were believed to exist; but they were also prescribed 
originally to relieve pain in these parts. Perhaps 



TREATMENT. EXTERNAL STIMULANTS. 145 

they have been esteemed mure valuable by American 
than by European physicians. Strong found that 
they checked vomiting and relieved coma, and stimu- 
lated the whole system ; but that in the more violent 
cases the skin was not vesicated by them. In the 
comatose variety, North says, "I have thought a 
blister applied to the nape of the neck a very useful 
remedy," and he also advises it to relieve pain in the 
head. Grallup says that "blistering ought to follow 
as soon as the patient has had warmth applied in the 
first instance." He prescribes the application of blis- 
ters to various parts of the body as general stimulants, 
as well as to the scalp and neck for their revulsive 
operation. Jackson states that vesication "has been 
followed by the most important good effects;" and 
Hale, while confirming all of these statements, quali- 
fies them with the remark that he found blisters to 
exhibit so much less power of relieving coma in this 
than in other febrile affections, that he at last ceased 
to prescribe them for that symptom. The substantial 
lesions (exudation, softening) in the one case, and the 
simple congestion in the other, suffice to explain this 
perfectly correct statement, and they also demonstrate 
the necessity of resorting as early as possible to these 
remedies, in order to obtain from them their full ad- 
vantage. Yet we think that Hale underestimated the 
epispastic treatment. Miner appreciated it more 
highly when he urged the necessity of stimulating 
the whole system by heat, &c. and the skin by rube- 
facients, before attempting to blister; then, he re- 
marks, " the freest application and repetition of 
them was attended with the most obvious beneficial 



146 EPIDEMIC MENINGITIS. 

effects." ..." In every case" he adds, ("the very 
mildest are not with safety excepted), the forehead, 
and in the severe, the vertex should be immediately 
blistered. Shaving the head and blistering it early ^ 
is more serviceable than any other external applica- 
tion." ..." So sensible were those patients who had 
their reason, of the beneficial effects of blisters, that 
they frequently begged to have them repeated." 
Ames furnishes equally positive testimony; he says, 
"blisters were found to be very valuable applied to 
the upper part of the vertebral column ; in mild and 
grave cases they seldom failed to remove or greatly 
relieve the cephalalgia. In the malignant varieties, 
also, the relief afforded by them was frequently very 
great." Hirsch remarks, that while this treatment 
may not exert a substantial influence upon the course 
or issue of the disease, it no doubt, in some cases, 
produces a diminution of the phenomena denoting de- 
pression; while Tourdes asserts that blistering the 
scalp, the spine, or other parts, increased the pain 
without mitigating a single symptom. It is evident 
from all of these statements taken together, that the 
utility of blisters in this disease is far from being uni- 
formly evident. It seems probable that in different 
epidemics they differed in their operation according 
to the presence or absence of unknown conditions; 
for the testimony, inconsistent as it is, cannot be re- 
jected. Were we to judge according to our own 
experience alone, we should assign to blisters, applied 
to the occiput and nuchse, a very high place among 
the remedies for certain forms of this disease; for we 
know that they relieve or remove pain, diminish de- 



TREATMENT. EXTERNAL STIMULANTS. 147 

lirium, spasm and coma, and therefore contribute as 
directly as any other remedies, if not much more so, 
to the favorable issue of the attack. But to accom- 
plish these salutary eifects of their use, they must not 
be employed when the disease assumes a malignant 
type, nor in any case after its constitution has become 
definitely fixed. Rollet is the only writer upon this 
subject, we believe, who recommends still more ener- 
getically revulsive agents. When the skin was not 
irritated by blisters, he employed the actual cautery 
on either side of the spinous recesses of the vertebrae, 
and from the head to the loins. Such "barbarous 
experiments," as Hirsch appropriately calls them, 
require no especial comment, particularly as no one 
has yet been bold enough to repeat them. 

In the early history of epidemic meningitis in this 
country we find much greater stress laid upon vari- 
ous means adapted to warm the patient's body than 
is to be observed in recent publications upon the sub- 
ject either in Europe or America. "The body must 
be got warm, the skin moist, and the energy of the 
pulse restored, or the life of the patient is gone," are 
the emphatic words of Strong. " The unanimity pre- 
dominant is sufficient to establish the fact respecting 
the utility of heating and sweating remedies," says 
North. According to Jackson, "the patient is first 
put into a warm bath (others insist that it shall be 
hot) or his feet bathed in warm water; then being 
well rubbed, he is to be laid in bed between blankets, 
and bedclothes added in proportion to his sensations 
or to his actual temperature w^hen his sensibility is 
very much diminished. Around him are to be placed 



148 EPIDEMIC MENINGITIS. 

bottles of hot water or billets of wood heated in boil- 
ing w^ater and wrapped in flannel, or he is to be 
WTapped in flannel wrung out of boiling water; sinap- 
isms are applied to the feet, and he is to swallow 
frequently some warm liquid," ... "^^ as hot infusions 
of the leaves of mint, pennyroyal and other similar 
plants, wine whey, wine and water, wine, brandy and 
other ardent spirits more or less diluted, camphor, 
sulphuric ether and opium. It is not generally 
thought useful to excite profuse sweating, but im- 
portant to maintain it from twenty to forty hours, 
and even longer in some instances. Soup and cor- 
dials are at the same time administered. Under this 
treatment most commonly the violent symptoms, and 
not very rarely all the appearances of disease have 
subsided." It is difficult to explain why a method 
which has in its favor the testimony of sound experi- 
ence, and the strongest possible reasons based upon 
analogy and the well established principles of therapeu- 
tics, should have fallen into such disuse as almost to 
have been forgotten. It cannot be because the type 
of disease requiring it is no longer met with, for, 
during the recent epidemic, physicians have become 
familiar with all its types and grades from the malig- 
nant to the inflammatory. One exception to the 
statement just made is furnished by Gordon, who 
says, "what I have seen most useful in the stage of 
collapse is external warmth applied to the entire sur- 
face by means of flannel bags containing roasted salt, 
applied along the spine, along the chest, inside the 
arms, and to the feet and legs, and between them." 
Internal Stimulants. — Except typhus fever, there 



TREATMENT. INTERNAL STIMULANTS. . 149 

is no disease in which the due administration of stimu- 
lants, and especially of alcohol, may become more 
essential to its successful treatment. But as the type 
of the disease varies from time to time between malig- 
nant and inflammatory extremes, the need of stimu- 
lants may be very slight or quite imperative. In 
point of fact, we find that while in the early history 
of epidemic meningitis in this country alcoholic and 
other stimuli were sometimes lavishly used, they 
formed but a subordinate and generally quite an in- 
significant part of the method usually adopted in 
Europe. How far the former course was pursued 
by our professional predecessors in imitation of the 
British treatment of typhus, or how far the latter 
plan was preferred by the French physicians of 1836, 
and subsequently, because they had been educated 
in the sanguinary school of which Broussais and 
Bouillaud were chief teachers; or how far, finally, 
the method of treatment in each case was determined 
by the predominant genius of each particular epi- 
demic, it may not be possible to determine; but, 
probably, each of these influences had its share in 
the result. Indeed, it seems quite certain that the 
earlier American physicians who did not know, or 
who only knew imperfectly, that one element of the 
disease was inflammatory, and who w^ere naturally 
influenced by those of its phenomena which led some 
among them to call it "sinking typhus," — it seems 
quite certain, we say, that they should at first incline 
to the free use of stimulants; just as it is natural in 
Europe, where its first epidemic visitations fell within 
the period when inflammation dominated in pathology. 



■ 



150 . EPIDEMIC MENINGITIS. 

and its inflammatory element was immediately dis- 
cerned, that the tendency should have been to coun- 
teract the disease by the most powerful weapons of 
the antiphlogistic armament. But time, which, in all 
things blunts the extreme edge and point of mischiev- 
ous error, has modified and, as we believe^ improved 
the therapeutics of this disease by demonstrating the 
dangers to which the sick are exposed, alike from an 
excessively stimulating and an extremely antiphlo- 
gistic method of treatment. 

The predominant view among American physicians 
of the first epoch with which we are concerned is well 
illustrated by the language and precepts of Strong, 
who says: "the first, the great, I had almost said the 
only indication of cure" is ''to support the vital energy, 
to raise the patient from his depressed state, and to 
hold him up till the disease passes off." He then 
adds that this purpose is to be carried out "by a 
proper use of nutritious diet, and of tonic, cordial and 
stimulating medicines." This "proper use," he clearly 
explains, will depend upon the condition of the patient; 
some cases will require only hot aromatic infusions, 
others wine, and others, again, brandy, either simple 
or spiced. He relates the case of a delicate female 
who took more than a quart of brandy in the course 
of eight hours, and a grain of opium every two hours ; 
and when the brandy could not otherwise be retained 
it was administered saturated with loaf sugar. This 
treatment roused her from a comatose, cold, and 
almost pulseless state, with constant hiccough besides, 
and saved her life. So North lays down the general 
precept, that "the tonic and stimulating method of 



TREATMENT. INTERNAL STIMULANTS. 151 

cure, as opposed to the debilitating plan, is the correct 
one," while he admits that the degree of its use must 
be regulated by the physician's sagacity. In regard 
to the form of stimulus, he remarks, '^fermented 
liquors of every kind may be used: of these claret, 
port and Madeira wine are preferred. Those who 
supposed distilled spirits are equally suitable, as 
general remedies, are much mistaken; though these 
may have their use as sudden stimulants." Again, 
he lays down the valuable rule that wine is often 
beneficial even where it is not necessary. Woodward 
observed that very large quantities of wine or ardent 
spirits may be given without doing any injury. Arnell 
says: "in some cases I have given a quart of brandy 
in six or eight hours with the happiest effect." Has- 
kell and his associates maintain that "the bold and 
liberal use of diffusible stimuli is the only safe and 
efficacious mode of treatment." Fiske, however, 
denied the necessity of this method in ordinary prac- 
tice, using stimulants only as auxiliaries in cases of 
extreme debility. Fish takes nearly the same view; 
but insists upon the liberal employment of alcohol by 
enema as well as by the mouth, and in conjunction 
with opium, spices, and external stimulants when re- 
action was difficult to obtain, or the vomiting obsti- 
nate. Other writers present, however, a very modified 
estimate of the treatment by stimulants and cordials. 
The committee of the Massachusetts Medical Society 
distinctly state that a division of opinion among phy- 
sicians existed respecting the utility of such articles, 
while there was a popular bias in their favor. They 
condemned their liberal and indiscriminate adminis- 



152 EPIDEMIC MENINGITIS. 

tration, and stated their conviction that a considerable 
proportion of the most judicious practitioners, and 
even of those who formerly employed that method, 
had learned by experience to regard it as highly in- 
jurious. At the same time they admitted the neces- 
sity of such medicines where the patients' faintness 
and debility gave the indication. Grallup adopted 
this judgment as his own, and Hale advocated the 
same discriminating use of these remedies. He also 
condemned their habitual employment at the begin- 
ning of the attack, while admitting their utility, and 
even necessity, where the prostration of strength and 
the apparent depression of the vital powers were ex- 
treme. A few teaspoonfuls of hot brandy he found 
often successful in arresting vomiting. "Alcohol," 
according to Miner, "was highly beneficial in some 
cases, and required to be employed freely in many; 
but it seemed not to be equally adapted to all, and 
on the whole, was of much less importance than 
opium." 

Nearly all of the more recent observers of epidemic 
meningitis assign a very subordinate position to alco- 
holic stimulants in the catalogue of remedies, and 
some, as Ames, Tourdes, Niemeyer, Hirsch, Mann- 
kopf, &c., make no mention of them whatever. In 
the late Irish epidemic they were, however, regarded 
as important. For our own part, while we consider 
these agents as altogether indispensable in the con- 
ditions of the system described by Miner, Hale and 
others, we are satisfied that their too free exhibition 
entails the gravest peril, by intoxicating the patients, 
and oppressing, where they are intended to rouse the 



TREATMENT. OPIUM. 153 

vital energies. On taking charge of the medical wards 
at the Philadelphia Hospital, we found that the patients 
were using as large quantities of alcohol as in typhus 
fever; but a very short period of observation rendered 
it so apparent that an excess in their administration 
was indulged in, that the dose of the medicine was 
first diminished, and finally it was omitted alto- 
gether, unless such special indications arose as have 
already been pointed out. This change was followed 
by a manifest improvement in the general aspect of 
the sick, and the subsidence of symptoms which, it 
then became evident, were attributable to a lavish 
use of stimulants rather than to the gravity of the 
disease. On the whole, we regard alcohol as a medi- 
cine which ought not to be included in the ordinary 
and systematic treatment of epidemic meningitis, but 
as a cordial to be held in reserve against those signs 
of failure in the power of the nervous system, which 
call for its administration in diseases of whatever 
name. In this, as in so many other respects, epidemic 
meningitis presents a striking contrast to typhus fever. 
Opium. — A very distinguished physician writing 
upon this disease, remarks: "even opium has upon 
the Continent enjoyed the reputation of curing this 
malady, hut upon what principle it is difficult to imagineT 
Cinchona, mercury and arsenic, have the reputation 
of curing, respectively, malarial diseases, syphilis and 
squamae, and although it is difficult to imagine upon 
what principle they do so, we apprehend that no one 
will contest their efficacy. A volume of speculations 
upon the nature of epidemic meningitis and on the 

action of opium are valueless in comparison with the 
11 



154 EPIDEMIC MENINGITIS. 

direct and accumulated proofs of the curative power 
of the medicine in this disease with which the htera- 
ture of our profession abounds. It interests us also, 
and in an especial manner, because it is an American 
remedy, and was not, as Hirsch and others state, first 
proposed by Forget or by Chauffard. By whom it 
was first employed may not be easy to determine, 
but that, in this country, it was in common use from 
the year 1808, the publications of that year and of im- 
mediately succeeding years abundantly demonstrate. 
Strong is the first who alludes to its use to relieve 
coma, and he urges that if the medicine is rejected 
from the stomach it should be administered by the 
rectum. "Opium," he remarks, "either pure, or in 
the form of laudanum, was found a most excellent 
stimulant in every stage of this disease. The best 
manner of exhibiting it appeared to be in small doses 
often repeated, so that the system should be constantly 
under a gentle influence from it. It tended to relieve 
pain, increase the excitement, and remove delirium 
and stupor. The necessary dose varied according to 
the mildness or violence of the symptoms, from ten 
drops of laudanum every hour to thirty drops every 
two hours. In those cases of the disease especially, 
which commenced with sudden and violent delirium, 
this medicine exceeded all others in its beneficial 
effects. In such cases, however, the dose required 
was often large, but when exhibited with great free- 
dom, it produced the happiest and most striking 
effects." A case is theii related in which excruciating 
agony in the head and maniacal delirium were pre- 
dominant symptoms. Sixty drops of laudanum were 



TREATMENT. OPIUM. 155 

administered every hour until 480 drops, or half a 
fluidounce had been taken in the course of eight 
hours. The whole of it was retained, and it subdued 
the excitement and allayed the pain, but produced 
no sleepiness nor any other apparent effect of opium. 
In a like heroic manner Haskell employed this remedy. 
He speaks of a young woman who recovered, but who 
during her illness took more than a quart of brandy 
and not less than twenty grains of good Turkey opium, 
and that without any evidence of intoxication. "In- 
deed," he adds, "we have been obliged frequently to 
exhibit ten grains of opium for a dose in some of the 
violent cases attended with strong spasms, and have 
never known it to produce stupor in a single instance." 
So Miner states that "a few cases imperiously re- 
quired half an ounce of the tincture in an hour, or 
half a drachm in substance, in the course of twelve 
hours, before the urgent symptoms could be con- 
trolled, and even some cases required a drachm in 
the same time. All these patients recovered." This 
sagacious observer and judicious thinker further says: 
" opium was the most important remedy in the severe 
form of this disease. . . . The whole of those patients 
whose symptoms were promptly met with opium in- 
variably recovered." Among the symptoms which it 
was particularly intended to relieve was one which 
is usually thought to be increased by narcotics, viz., 
coma. This object is particularly mentioned by 
Strong; Hale, also, who advised tincture of opium 
with oil of peppermint or lavender, frequently re- 
peated, to relieve coma, remarked: "whatever may 
be the explanation of its mode of action, it is certain 



156 EPIDEMIC MENINGITIS. 

that this was a powerful agent in removing the deepest 
comas which were not absolutely irrecoverable." Such, 
indeed, is substantially the testimony of Woodward, 
Bestor, Arnell and others, of that period, who em- 
ployed opium for pain, vomiting, diarrhoea, and sleep- 
lessness. Among the writers of the first period of 
the prevalence of the disease in this country, Gallup 
is the only one who passes an unfavorable judgment 
upon this drug. He employed it only in cases at- 
tended with cholera morbus. Otherwise he discarded 
it altogether. "ObserAdng the bad effects of opium," 
he remarks, "in certain cases not in my control, I had 
determined to see if the disease could not be managed 
without it;" and he then states that of eighty-one de- 
cided cases committed wholly to his care, and treated 
without opium, one case only proved fatal. It is evi- 
dent that such a low rate of mortality could not have 
been furnished by cases of this disease requiring any 
active treatment at all. 

Of more recent American observers the judgment 
is not uniform upon this subject. Ames does not 
appear to have tested the opium treatment, for his 
whole opinion in regard to it is contained in these 
lines: "from what I saw of it I can scarcely say that 
it was generally safe to give opium in the inflamma- 
tory malignant variety, or that it was of any use in 
the congestive mahgnant form. In the other varie- 
ties it was a safe remedy, and very valuable as an 
anodyne merely." Upham only notices opium as a 
means of procuring sleep at night. Russell employed 
it to control delirium; and Woodward prescribed it 
if the skin was moist, but thought that it aggravated 



TREATMENT. OPIUM. 157 

the head distress. But, on the other hand, Jewell 
affirms that "opium stands not only at the head of 
the list of stimulants, but also at the head of remedial 
agencies in this disease;" and Kendall says, "ano- 
dynes, even in large doses, in the early stage, seemed 
to increase the watchfulness; but after the first period 
had passed, and an evacuation from the bowels had 
been procured, they often quelled the intense rest- 
lessness like a charm." 

The greater number of European physicians who 
made use of this remedy, prescribed it in doses quite 
too small to serve any good purpose, except as a pal- 
liative. This statement is true of the practice pursued 
by Forget, Tourdes, Gaskoin, Sanderson and others. 
Some, also, like Bricheteau, adopted, as an argument 
against its use, the vicious question, how could it do 
good? But others, like Chauffard, who administered 
it in doses of from three to fifteen grains pronounce 
it to be incomparably the most efficacious remedy. Its 
most earnest advocate was Boudin. He increased the 
dose of the drug in proportion to the severity of the 
symptoms, and frequently administered from seven 
to fifteen grains in a single dose at the commencement 
of the attack, and subsequently one or two grains 
every half hour. This method was steadily pursued 
until the patient began to be sleepy, or his symptoms 
abated, and then the use of the medicine was still 
persevered in, although its dose was diminished. 
During the active stage of the disease a remarkable 
tolerance of the drug was observed. It never pro- 
duced constipation, or at least did not increase that 
which already existed. Our own observations cor- 



158 EPIDEMIC MENINGITIS. 

roborate these results fully. We were in the habit 
of giving one grain of opium every hour, in very 
severe, and every two hours in moderately severe 
cases, and in no instance was produced either nar- 
cotism or even an approach to that condition. Under 
the influence of the medicine the pain and spasm sub- 
sided, the skin grew warmer and the pulse fuller, and 
the entire condition of the patient more hopeful. It 
seemed probable, however, that the full benefit of the 
opium treatment could be received by those only who 
were subjected to it in the early stages of the attack. 
Direct experience is here in perfect accord with the 
expectation which a knowledge of the pathological 
processes involved in the disease would naturally 
suggest. 

Cinchona and Quinia. — It has been very customary 
for those who had to treat epidemic meningitis during 
its late prevalence to associate large doses of sulphate 
of quinia with the opium which they administered. 
A careful examination of the evidence does not prove 
either the necessity or the utility of this association. 
In the early American epidemics, before quinia was 
discovered, physicians made use of Peruvian bark in 
powder, tincture, decoction, &c. But two observations 
were speedily made; the one was that the stomach 
would not tolerate doses of the bark large enough to 
display antiperiodic virtues, and the other was that 
smaller doses were perfectly unavailing against the 
proper elements of the disease. The medicine then 
was made use of as a mere tonic during the decline 
of the attack and during convalescence. Such is the 
testimony of Strong, North, Fish, Jackson, Hale, &c. 



TREATMENT. CINCHONA AND QUINIA. 159 

After the introduction of the alkaloids of cinchona 
into medical practice, the sulphate of quinia was 
largely employed for the cure of the disease we are 
studying. But its effects were not generally regarded 
as salutary. Love tells us that when, owing to the 
apparently periodical character of the symptoms, large 
doses of quinia seemed to be indispensable, the}' were 
injurious and not beneficial. Ames had "but little 
to say in favor of this medicine." . . . "When the dis- 
ease was attended with a fever which was regularly 
remittent, the meningitis appearing as an appendage, 
or as if engrafted on a remittent fever, quinine did 
occasionally arrest the paroxysms, but more slowly 
and with greater difficulty than in other fevers. As 
a remedy in other varieties it cannot be recommend- 
ed; its use here, if not hazardous, never affording 
much encouragement to repeat it." Boling "saw it 
succeed in two intermittent cases which were not 
very violent, while it failed in others of a graver 
character." Upham states that quinia, in some in- 
stances to the extent of sixty or even eighty grains 
was given within twelve hours from the first attack, 
but without effect; and Jewell found it useful only 
as a tonic. In Europe all of the most reliable ob- 
servers of this disease formed the same estimate of 
quinia in its treatment as physicians had formed in 
the United States; and this statement refers particu- 
larly to Tourdes, Faure Yillars, Barrilleau and Bros- 
sard, Sanderson, Mannkopf and Hirsch. C. Brous- 
sais, indeed, presents as a case of cerebro-spinal 
meningitis cured by sulphate of quinia, one of com- 
pletely intermittent paroxysms with spasms of the 



160 EPIDEMIC MENINGITIS. 

flexors of the forearms ! Evidently an error of diag- 
nosis was committed. Chanffard also relates, as a 
case in point, one which recovered after five grains 
of opium and fifteen of sulphate of quinia had been 
administered. But the share of the opium in this 
and similar instances must not be overlooked. On 
the whole, it is evident that opium alone, in large 
doses, will control the disease in many instances, and 
that quinia in large doses will remove the complication, 
when it exists, occasioned by miasmatic poisoning; 
but there is no evidence sufficient to show that epi- 
demic meningitis has ever been cured by sulphate of 
quinia alone. In accordance with general belief in 
the efficacy of this medicine we have usually associ- 
ated it with full doses of opium; but should the occa- 
sion again be presented, we shall feel constrained to 
discard sulphate of quinia except as a tonic during 
the decline of the attack. 

Alteratives — Mercurials. — It is very certain 
that mercury has entered more generally into the 
treatment of epidemic meningitis than any other 
medicine; and, were this fact alone considered, the 
propriety of continuing to prescribe it could scarcely 
be called in question. When, moreover, it is remem- 
bered that of all medicines for the cure of other forms 
of meningitis, this one has the greatest weight of 
testimony in its favor, there would seem to be a de- 
cided preponderance of motives for its employment 
against the epidemic under discussion. We leave 
out of consideration here the emphatic judgment of 
many recent therapeutists against it as a remedy for 
any form of inflammation, believing that the grounds 



TREATMENT. ALTERATIVES: MERCURIALS. 161 

of their conclusions are less extensive than they are 
claimed to be, if, indeed, they are not altogether un- 
sound. But in this, as in all similar cases, the proof 
by analogy is one that requires to be very cautiously 
and liarrowly scrutinized. It very seldom affords a 
substantial basis for practice. At the best, it can 
only be regarded as a suggestion for the trial of a 
medicine, whose real utility must afterwards be de- 
termined by direct observation and experiment. To 
those who regard epidemic meningitis as a purely 
zymotic or blood disease, and the meningeal lesion as 
a subordinate or accidental morbid element, or who 
consider the affection a form of typhus fever, the ap- 
plication of mercury to its cure must appear an ex- 
tremely irrational and highly imprudent measure; 
while those who view it as preeminently and primarily 
an inflammation, may urge in support of the use of 
mercurials in its cure, that it is justified by established 
doctrine in regard to the therapeutical operation of 
these medicines. But if we look upon the disease as 
one in w^hich a zymotic and an inflammatory element 
are combined in varying proportions, it would seem 
to follow that while mercury might benefit one class 
of cases, it would seriously injure the other. And if, 
once more, we turn to the only true source of light 
in resolving such questions, we shall perhaps find 
that experience, as final arbiter, pronounces an equivo- 
cal judgment, and leaves the problem virtually unre- 
solved. We shall perhaps learn that while this medi- 
cine has been more generally employed than any 
other, the proofs of its salutary operation, as distin- 



162 EPIDEMIC MENINGITIS. 

guished from vague impressions^ are far from being 
precise or clear. 

Looking, now, to historical testimony for light upon 
this question, we learn that neither North nor Strong 
nor Miner nor Gallup employed mercury in the treat- 
ment of epidemic meningitis. Miner, referring to it 
as a purgative, says of this class of medicines, '^Jiwant 
'per casiim, nocent per se ;^ and he adds, ^4n a few bad 
cases, in which a slight mercurial action was excited, 
it was of no sort of service." In Europe we find the 
following testimony given by Tourdes: "frictions with 
mercurial ointment upon the scalp, the thighs, in the 
armpits and along the spine were employed, while 
calomel was administered internally. In three cases, 
one of which was fatal, salivation occurred. In spite 
of the large doses and the steady application of this 
medicine, it was generally unavailing." Hirsch, also, 
regards mercurial purgatives as of slight value, and 
mercury as an antiplastic medicine of very question- 
able value. He adds that, even apart from its mis- 
chievous effects in certain cases, the observations of 
Tourdes, Guepratte, Chauffard, Falot, Corbin, Lind- 
strom, Wunderlich and others, do not lead us to repose 
much confidence in its efficacy. On the other hand, 
Bestor writes: "within three or four hours from the 
attack, I usually gave from eight to ten grains of 
calomel, not with a view to purge on the first day, 
but to act as a stimulus to the system, and to prepare 
the bowels to be moved by injections on the following 
day;" and Arnell, Fish and Woodward advise the 
same method, which, it need scarcely be remarked, 
is justified neither by theory nor experience. Others, 



TREATMENT. ALTERATIVES: MERCURIALS. 163 

more rationally, sought to produce the constitutional 
effects of the medicine. "If," says Fiske, "we were 
bold and liberal in the use of anything, it was calo- 
mel" until a shght affection of the glands was obtained ; 
and Danielson and Mann gave to a child one hundred 
grains of calomel in doses of three grains each, when 
the patient died, — as was most natural that it should do, 
although the authors style this method "a stimulating 
process." According to Jackson, the success of the 
mercurial practice "was not exceeded by that of any 
other." But this judgment is afterwards qualified by 
the remark that although in cases where life is imme- 
diately threatened the remedy cannot be relied on to 
avert the danger, yet that it is of great value where 
the most urgent symptoms are removed by other 
remedies. This conclusion is less favorable, perhaps, 
than the authors appear to have regarded it. Ames 
employed mercury almost exclusively to produce 
its constitutional effects, and regarded its beneficial 
influence as more prompt and permanent than that 
of blood-letting. It was, he believed, always safe if 
not always effectual. Upon this testimony Drake 
remarks that "it cannot be regarded as decisive." 
Kendall found "calomel in large doses" the best 
remedy in the first stage of the disease ; Dickson 
purged with calomel and rhubarb followed by croton 
oil; Iredell regarded it "of the utmost importance to 
push the mercury to the extent of producing its con- 
stitutional effects;" and Upham reports small doses 
of calomel with ipecacuanha to have had a good effect 
in several instances. Renzi attributes to blue mass, 
among other effects, the resolution of the abdominal (?) 



161 EPIDEMIC MENINGITIS. 

inflammation, and asserts that a cure followed the pro- 
duction of mercurial sore mouth. He was under an 
impression that it directly neutralized the poison and 
expelled it from the system. According to Mayne, 
the chief reliance is to be placed on the internal and 
external use of mercury; and Gordon recommends 
small doses during the stage of reaction. 

It cannot be doubted that these witnesses are far 
from agreeing with one another. Between those w^ho 
absolutely neglect, or positively condemn the use of 
mercurials in epidemic meningitis, and those who 
eulogize them as the best of all remedies, an impass- 
able gulf is fixed quite as wdde as that which separates 
those who found in mercury a "stimulus to the sys- 
tem" or an "alterative of the minima vascula" (Jack- 
son), and those who attributed to it an antidotal action 
upon the poison itself. The mode of its curative action 
would be of interest, certainly, to determine, but it is 
of a very remote and subordinate interest when com- 
pared with the primary and capital problem, is the 
medicine curative at all? But upon this question we 
have no satisfactory data; no comparison of cases 
treated with and without mercury; no enumeration of 
the special symptoms which it favorably influences; 
no statement of the mortality occurring under its use. 
Its virtues, according to some, depend upon its pur- 
gative operation, while others regard its salivant 
action as alone efficient. Are the former right when 
experience demonstrates that all other purgation in 
this disease is mischievous ; or are the latter right, 
when Tourdes, who carried the method furthest, un- 
equivocally condemns it? It cannot be alleged that 



TREATMENT. ALTERATIVES: MERCURIALS. 165 

the epidemic which Tourdes witnessed was one ill 
adapted for the mercurial treatment. To do so would 
be not only to admit that for some types of the dis- 
ease such medicines are unsuited, it would also be 
to make an erroneous statement; for the epidemic 
at Strasburg was the one. above all others, which de- 
monstrated that the anatomical character of the disease 
consists in an exudative inflammation of the cerebro- 
spinal meninges. Shall it then be denied that mercury 
is a suitable agent in the cure of this disease? By no 
means, unless the proposition is made a general one, 
including all of the multiform types which epidemic 
meningitis presents. Its malignant and typhoid forms 
must, of course, be regarded as unsuited for any treat- 
ment by mercury. A very large proportion of other 
cases tend to cure rather than to death, and do not 
demand, even if they do not absolutely forbid, the 
employment of so debilitating a remedy as the one in 
question. But there remains another group of cases 
whose general expression is sthenic; in which the 
pulse is comparatively strong, the skin warm if not 
hot, the pains in the head, spine and limbs severe, 
. and the tetanic phenomena marked ; — in these, if in 
any, the use of mercury would seem to be justified 
by analogy, and perhaps, though of this the evidence 
is not conclusive, by direct observation. We have 
never employed the medicine in such cases, nor, in- 
deed, in any others, for the remedies before considered 
appeared to be sufficient for the cure; but had w^e an- 
other epidemic to encounter, we should certainly put 
to the test whatever virtues mercury might possess 



166 EPIDEMIC MENINGITIS. 

for mitigating the severity of the disease, and hasten- 
ing its cure. 

There remain to be noticed several other medicines, 
concerning which at different times favorable opinions 
have been expressed. One of these, and the earliest, 
in point of time, is the solution of arsenite of potassa. 
It was originally exhibited in this disease by Daniel- 
son and Mann. What first suggested to them the 
idea of using it does not appear; but they resorted to 
it after the failure of evacuants and of bark and wine, 
giving to a child three years old "two drops in a 
tablespoonful of wine." The influence of the wnne 
in this prescription was certainly not either negative 
or trifling. A further trial of it by other physicians 
led to the judgment expressed by Strong several years 
later, that "although it has not been sufficient in all 
cases, still it has appeared to be a safe and very use- 
ful medicine, and in many cases the most happy 
effects have evidently been produced by it." It was 
regarded as a direct stimulant of the most powerful 
description. "It tends," says Strong, "to increase 
the excitement, often in the course of a few minutes 
producing a very pleasant sensation of w^armth through 
the whole system; and tends more than any other- 
medicine to remove the cold and singular sensation 
at the stomach, which has been mentioned as being 
so peculiarly distressing." Fish ascribed similar effects 
to the medicine, and took the same view of its ope- 
ration. But the Massachusetts committee, from the 
survey of a wide field of experience, expressed no posi- 
tive judgment as to its value; and in 1825, Miner 
wrote, " arsenic was highly serviceable when the head 



TREATMENT. IODIDE OF POTASSIUM, ETC. 167 

was much affected, and the stomach at the same time 
torpid. In some irritable cases it ans\yered well, but 
it was necessary to adjust the dose very accurately, 
in order to have its full effect on the one hand, and 
not offend the stomach on the other." The medicine 
was also used by Hale, Gallup and other physicians 
of the day, either for the purposes just indicated, or 
as a tonic during convalescence. In the history of 
later epidemics, whether in this country or in Europe, 
we have met with no reference to the use of arsenic, 
nor have we employed it in our own practice ; but if 
the statements which have been quoted are correct, 
the omission of this medicine in the treatment of epi- 
demic meningitis is a grave fault. 

Iodide of potassium has been used during the de- 
cline of the disease for the purpose of exciting the 
absorption of the lymph effused beneath the meninges. 
There is a theoretical probability of its usefulness. 

Several physicians, disregarding the conclusions of 
universal experience in favor of opium, and preferring 
to follow the a priori road which always leads to dis- 
appointment or error, concluded that since belladonna 
and ergot had been shown to diminish vascular action 
in the cerebro-spinal axis, they necessarily become 
specific remedies for cerebro-spinal meningitis. In- 
deed, one writer so far forgets the rules of medical 
logic as to conclude that because, in his opinion, the 
views of Brown-Sequard on the action of belladonna 
and ergot are correct, therefore opium and alcohol 
"are decidedly contraindicated in the treatment of the 
disease under consideration." Upham states that in 
1863 Haddock recommended ergot, upon the grounds 



168 EPIDEMIC MENINGITIS. 

just referred to, duriDg the epidemic at Newbern, 
North Carolina^ and that '^several of the cases thus 
treated recovered." Under the impression which 
thus originated as to its efficacy ergot was prescribed 
by Borland in three cases, which also recovered. In 
California, Peake advised its use on theoretical grounds, 
but made no statements of its success in his hands. 
Woodward appears to have allayed pain in the head 
in this disease by the use of belladonna; and Gordon, 
in Dublin, prescribed two grains of sulphate of quinia 
and one grain of extract of belladonna every three 
hours in a case marked by collapse, dark eruption, 
extreme pain in the head and neck, and strabismus. 
When it is known that the head was at the same 
time shaved and blistered, the influence of the bella- 
donna in promoting the cure may be regarded as more 
than equivocal. The same writer used belladonna 
with advantage, externally, to relieve dysphagia, and 
around the eyes in cases of ulcerated cornea, &c. 

Diet. — The remarks which have been made in re- 
gard to the appropriateness of diffusible stimulants in 
those cases of epidemic meningitis which are charac- 
terized by exhaustion, imply the necessity of employ- 
ing a nutritious diet under similar circumstances. But 
such a diet is hardly less applicable in ordinary cases 
of the disease which do not require the exhibition of 
alcohol in any form. In European epidemics this im- 
portant matter has too often been either overlooked, or 
a degree of abstinence from food enjoined which we 
cannot but regard as inappropriate if not injurious. 
It would seem incredible to any one acquainted with 
the disease that an honorable and skillful physician 



TREATMENT. DIET. 169 

had advised absolute diet and emollient drinks in its 
treatment (Rollet), if other heroic measures of an op- 
posite nature and which no one has had the courage 
to imitate, had not also been recommended by him as 
the most efficient means of cure. Hirsch, also, after 
stating that in the commencement of the attack there 
is generally complete anorexia, declares that even 
after some appetite has been felt, the strictest rules 
of diet should be observed, and only the blandest 
articles of food allowed. Such are not the conclusions 
to which experience really points, nor are they justi- 
fied by a thorough study of the genius of the disease. 
If its history has been correctly written in these 
pages, it presents few cases of a purely sthenic nature; 
its predominant tendency is towards a typhoid state, 
or one of pure asthenia. Now, nothing can be con- 
sidered more firmly established than the precept that 
the treatment of a disease should be governed by its 
type rather than by the local morbid process which 
accompanies it. It appears, therefore, that even upon 
general grounds a strict diet is not indicated. Again^ 
if it be true that opium and stimulating and tonic 
remedies are more appropriate for the cure than the 
antiphlogistic and evacuant methods, it cannot at the 
same time be true that a rigid abstinence from food 
should be enjoined. Once more, those who accept the 
doctrine that all disease, even sthenic inflammations, 
and a fortiori Rsthenic and typhoid conditions, are only 
proofs of a struggle between the natural and the 
morbific powers in which the former are to be sup- 
ported by every expedient, must, of course, admit 
that in this case there is a loud and emphatic call for 

12 



170 EPIDEMIC MENINGITIS. 

supporting measures, including nutritious food. Our 
own practice has, in general^ been to prescribe such 
food as it is customary to employ in typhus fever, 
having been led thereto by the debility of the patients, 
the uncertain and often compressible pulse, the cool 
extremities, the eruptions upon the skin, the absence 
of alvine disturbance in the greater number of cases, 
and the evident dependence of the gastric derange- 
ment upon irritation of the brain. In this, it ap- 
pears, we did but follow the example of early Ameri- 
can physicians, who were guided by the prevalent 
symptoms to direct a nutritious diet, as they were 
also led to prescribe a liberal use of opium. Strong 
insists firmly and repeatedly upon this plan, advising 
^^soup made from chicken, veal, mutton and beef, 
richly seasoned with pepper and savory herbs," and 
adds, "this is a very important part of the process 
and ought by no means to be neglected." These 
articles were advised to be given during the height 
of the disease; and afterwards, it is added, ^'the 
stomach soon begins to crave something more solid 
than scup; oysters, beefsteak, cold ham, or neats' 
tongue are received with peculiar relish. Often have 
I seen convalescents when they had hardly strength 
enough to raise themselves in bed, make a hearty meal 
of the above-mentioned articles, which were received 
with great satisfaction, sat well upon the stomach, 
and were well digested and assimilated." The same 
advice, substantially, is given by Hale, who recom- 
mends soups at first and then solid food, for the latter 
of w^hich he observes that the patients early have an 
appetite; and by Jackson and his colleagues, who 



TREATMENT. REGIMEN. 1 7 I 

direct the most nutritious food that can be digested, 
and add, that it is not very important to abstain from 
it even during the first stage of the disease. These 
precepts are the same, substantially, which are fur- 
nished by all American writers whose experience 
entitles them to weight in the decision of this ques- 
tion, which we hold to be of capital importance in 
the management of epidemic meningitis. 

The general regimen to be observed consists in the 
use of the ordinary measures which are adapted to 
promote the repose of the patients in low forms of 
fever ; but an additional suggestion, to which the great- 
est importance was attached by the writers just re- 
ferred to, is that great care should be taken to prevent 
the patient from making any unnecessary exertion, 
and especially from, assuming the erect or even the 
sitting posture before convalescence is fully estab- 
lished. The necessity of these precautions arises 
from the singular debility which characterizes so 
many cases of the disease, and which, as was before 
pointed out, suggested the title of typhus syncopalis, 
which was conferred upon it. 



BIBLIOGRAPHY. 



* 



Adams, J. .F. A., Boston Med. and Surg. Jour., Aug. 1866, 

p. 66. ^ 

Ames, S., N. Orleans Med. and Surg. Jour., Nov. 1848. 
Anderson, W., Trans. Med. Soc. of Penna. 1864, p. 43«. 
Andral, Gr., An Essay on the Blood in Disease. x\m. ed., p. 73. 
Anonymous, N. England Jour, of Med. and Surg., i. 151; ii. 228, 

241; iii. 166; iv. 238. 

British Med. Jour., July 8, 1865. 

Lancet, April, 1865, p. 436; May, 1865, p. 549. 

Armstrong, W. Gr., Am. Jour, of Med. Sci., July, 1866, p. 279. 
Arnell, D. E,., American Medical and Philosophical Register, vol. 

i. p. 12, and p. 176. 
Atlee, W. F., Amer. Jour, of Med. Sci., July, 1864, p. 94. 

• 
Baldwin, W. 0., Amer. Jour, of Med. Sci., Oct. 1866, p. 321. 
Baltzell, W. H., Am. Jour, of Med. Sci., Oct. 1865, p. 368. 
Banks, Dr., Dublin Quart. Jour., May, 1866, p. 448; and Feb. 

1867, p. 98; Dublin Med. Press, June, 1867, p. 580. 
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ix. 894. 
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Bestor, J., In North, 1810. 

Black, J. R., Am. Jour, of Med. Sci., April, 1865, p. 345. 
Boling, W. M., N. Orleans Med. and Surg. Jour., May, 1847, p.- 

732. 
Borland, J. N., Boston Med. and Surg. Jour., May, 1865, p. 309. 

* This list includes only the original monographs, reports, &c., referred to 
in the body of the Essay. A more general and complete Bibliography of 
European treatises is furnished by Hirsch and also by Mannkopf. 



BIBLIOGRAPHY. 173 

Boudin, C. M., Histoire du Typhus Cerebro-Spinal. Paris, 1854. 

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Burdon-Sanderson, J. Beport of the results of an inquiry into 

the epidemics of eerebro-spinal meningitis prevailing about the 

Lower Vistula. London, 1865. 
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Catlin, B. H., Trans of Amer. Med. Assoc., xvi. 471. 

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Danielson & Mann, Medical and Agricultural Register. Also, 

in North. 1806. 
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Philadelphia, 1854. 
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Edes, R. T., Am. Jour, of Med. Sci., July, 1864, p. 274. 
Ellis, C, Boston Med. and Surg. Jour., June, 1864. 



174 EPIDEMIC MENINGITIS. 

Fassett, 0. F., Trans, of Vermont Med. Soc., 1864, p. 43. 

Faure-Villar, Bulletin de I'Aead. Royale de Med., 1841, vi. 
689. 

Fenner, E. D., Southern Medical Reports, ii. 17. 

Fish, H., Remarks on the Spotted Fever as it prevailed in Hart- 
ford, Conn., in 1809. In Trans, of the Physico-Medical Society 
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Fiske, 0., In North. 1810. 

Foot, W., Philadelphia Medical Museum, 1808, v. 248. 

Frentzel, Med. Times and G-azette, April 22, 1865. 

Frothingham, W., Amer. Med. Times, April, 1864, p. 207. 

G-AMAGE, W., Some account of the Fever, &c. of 1817 and 1818. 
Boston, 1818. 

Gervis, H., Med.-Chir. Trans. (1811), ii. 234. 

Gilbert, D., Am. Jour, of Med. Sci., July, 1864, p. 140; July, 
1865, p. 93. 

Gillkrest, J., London Med. Gazette, July, 1844, p. 455. 

Githens, W. H. H., Notes of 98 cases. Amer. Jour, of Med. Sci., 
July, 1867, p. 17. 

Green, T., Trans. Med. Soc. of Penna., 1864, p. 472. 

Gallup, J. A., Sketches of Epidemic Diseases in the State of Ver- 
mont. Boston, 1815. 

Gaune, Archives Generales de Med., Janv. 1858, p. 1. 

Gerhard, W. W., Amer. Jour, of Med. Sci., July, 1863, p. 105. 

Gordon, S., Dublin Quart. Jour., May, 1867; Dublin Med. Press 
and Circular, May, 1867, pp. 508, 551. 

Greene, J. S., Boston Med. and Surg. Jour., Nov. 1865, p. 256. 

Hale, E., History and Description of an Epidemic Fever, com- 
monly called Spotted Fever. Boston, 1818. 

Hartshorne, H., Amer. Jour, of Med. Sci., July, 1864, p. 93. 

Haskell, A., Spooner, M., and Holmes, F., In North. 1810. 

Haverty, Dublin Med. Press and Circular, May, 1867, p. 525. 

Hayden, Dublin Med. Press and Circular, May, 1867, pp. 530, 
579. 

Hicks, B. J. and Taylor, B. F., New Orleans Med. and Surg. 
Jour., July, 1847, p. 49. 



BIBLIOGRAPHY. 175 

Hirsch, A., Handbuch der Historisch-Geographischea Pathologic, 
i. 163; Die Meningitis Cerebro-Spinalis Epidemica. Berlin, 
1866. 

Holbrook, Boston Med. and Surg. Jour., June, 1865, p. 369. 

Hughes, J., Dublin Med. Press and Circular, May, 1867, p. 510. 

Hutchinson, J. H., Am. Jour, of Med. Sci., July, 1866, p. 125. 

Jackson, vide Welsh. 

Jenks, E. W., Buffalo Med. and Surg. Jour., Oct. 1863, p. 81. 

Jewell, J. S., Cerebro-Spinal Meningitis; a report made to the 

Illinois State Med. Society. Chicago, 1866. 
Jewell, W., Am. Jour, of Med. Sci., July, 1864, p. 129. 

Kay, Isaac, Boston Med. and Surg. Jour., June, 1864. 
Kempf, M., Amer. Jour, of Med. Sci., July, 1866, p. 55. 
Kendall, J. V., Trans, of Med. Soc. of the State of New York, 

1858, p. 96. 
Kennedy, H., Dublin Med. Press, June, 1867, p. 551. 
Ketchum, B. T., Trans, of the Vermont Medical Society, 1865. 
Kirtland, J. P., American Med. Recorder, xiv. 441. 
Klebs, Yirchow's Archiv, xxxiv., 327. 
Kohler, H., Monographic der Meningitis Spinalis. 1861. 

Law, R., Dublin Quart. Jour., Nov. 1849, p. 317; May, 1866, 
p. 288. Med. Press and Circular, June, 1867, p. 548. 

Lebert, H., Anatomic Pathologique, vol. ii. p 22. Paris, 1858. 

Lecdom, E. C, Trans. Med. Soc. of Penna., 1864, p. 415. 

Lefevre, M., Eecherches Historiqucs sur la Maladic qui a regne 
au bagne de Rochcfort en 1839. Paris, 1840. 

Lente, F. D., Am. Med Times, July, 1864, p. 14. 

Levick, J. J., Trans, of Amer. Med. Association, xvii. 311. Am. 
Jour, of Med. Sci., July, 1864, p. 135; July, 1865, p. 277. 

Levy, M., Bull, de I'Acad. Emp. de Med., xiv. 765; xv. 20. 

Lidell, J. A., Am. Jour, of Med. Sci., Jan. 1865, p. 17. 

Lionet et Petit, Bull, de TAcad. Imp. dc Med., xiv. 952. 

Love, T. N., N. Orleans Med. and Surg. Jour., July, 1848. 

Lyman, E., In North. 1808. 

Lyons, Dublin Med. Press and Circular, May, 1867, p. 509. 



176 EPIDEMIC MENINGITIS. 

Mann, J., Medical Sketches of the Campaigns of 1812, '13 and 

'14, p. 19, and p. 306; vide Danielson. 
Mannkopf, Ueber Meningitis Cerebro-Spinalis Epideraica. Braun- 
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Martin, E., An Essay on the Epidemics of the Winters of 1813 

and 1814, p. 74. Baltimore, 1815. 
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389. 
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xi. 243. 
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Millar, J., Epidemic in St. Petersburg. Edinb. Journ., xi. 225. 
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dletown, 1823. 
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Spotted Fever of New England. Middletown, 1825. 
Minot, F., Boston Med. and Surg. Jour., March, 1864. 
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Murchison, C, Lancet, April, 1865, p. 417. 

NiEMEYER, F., Die Epidemische Cerebro-Spinal Meningitis. 

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Oliver, J. L., Trans. Med. Soc. of Pennsylvania, 1864, p. 429. 

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Parks, Jr., L., Boston Med. and Surg. Jour., March, 1864; Pub- 
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Petit, vide Lionnet. 

Foley, F. B., Trans. Med. Soc. of Penna., 1863, p. 237. 

Prewitt, T. F., St. Louis Med. and Surg. Jour., 1865, p. 205. 



BIBLIOGRAPHY. 177 

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XIY., xi. 163. 

13 



178 EPIDEMIC MENINGITIS. 

Wait, R,, Med. Repository, 1810, p. 391. 

Warren, vide Welsh. 

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pp. 268 and 417. 



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